Neurology & Pain Management Coding Alert

Neurologists often may be tempted to miscode t-PA administration for stroke because the correct billing procedure requires extra effort. But by using the proper codes, they can ethically maximize their reimbursement.

This procedure involves a specialized stroke team, critical care codes and extensive time spent talking with the family (even if the procedure ultimately is not performed). But the code for the procedure only includes administrationsomething the nurse usually doeswith no fee to the physician. So the physician must bill the evaluation and management (E/M) service codes to be reimbursed.

Choosing the Correct Code

The correct code for t-PA administration is 37195 (thrombolysis, cerebral, by intravenous infusion). This code is for administration only and contains no physician work value. The fee includes evaluation and monitoring of the stroke patient. Consequently, the key is to bill for the services provided while evaluating and monitoring the patient during t-PA administration.

Many neurologists are incorrectly using 37201 (transcatheter therapy, infusion for thrombolysis other than coronary), because it does have physician work relative value units (RVU). But this is the wrong code to use. As is 36500 (declotting by thrombolytic agent of implanted vascular access device or catheter), a new code in CPT 2000, which is for flushing implanted catheters, such as those for central venous lines.

To be adequately reimbursed, neurologists must be very careful to include other work they doparticularly by using the critical care and prolonged services codes. But they also must ensure that the services qualify for these codes.

Theres a very wide level of interpretation for use of the critical care codes with this procedure, says Bryan Soronson, administrator of the department of neurology at the University of Maryland Medical Center in Baltimore. Auditors look at things differently sometimes.

To be on the safe side, Soronson says, patients must be neurologically unstable before the physician can use the critical care codes. But this would apply to almost all
t-PA patients because there is a small window during which t-PA can be administeredwithin three hours after suffering a stroke. In my opinion, these patients are all neurologically critical, he adds.

Mark Nuwer, MD, representative to the American Medical Associations CPT Advisory Committee for the American Academy of Neurology, says that intravenous
t-PA administration is, by itself, qualification for use of the critical care codes. Just the fact of using t-PA, which has a 12 percent risk of a fatal cranial hemorrhage, is enough justification, states Nuwer, professor of neurology in the Department of Neurology at the University of California, Los Angeles. Because critical care codes are time-based, they are ideal for the work a neurologist does while t-PA is being administered. The neurologist sits with the patient while getting imaging scans, he says. He has to be there in case the patient strokes out. The t-PA administration is in and of itself a critical care situation. The neurologist could even be at the central ICU nurses station, interviewing the family member who found the patient, says Nuwer, and bill the critical care codes. This is all critical care time, he says.

The bottom line is this: Bill for critical care if you are attending a stroke patient receiving t-PA. Theres no reason why the neurologist shouldnt use the critical care codes, says Nuwer. They are appropriate in this scenario and should be used, he adds.

Critical Care Codes

Usually, the patient is admitted through the emergency room and then goes to the intensive care unit for the t-PA administration. If the neurologist is providing hands on care, administering the drug and monitoring the patient during this time, the critical care codes (99291-99292) may be used.

The key is to document the time spent administering the drug and monitoring the patient. But neurologists cannot use the critical care codes for time spent being on call for any changes in the patients status, such as blood pressure or neurological signs (for this work, physicians would use the prolonged services codes, described on page 27).

The critical care codes are much less restrictive in CPT 2000, which should make them easier to use in stroke situations. In CPT 1999, critical care services were reserved for the unstable critically ill or unstable critically injured patient who requires constant physician attendance. These services were to be provided to but not limited to, patients with central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic or respiratory failure, postoperative complications, or overwhelming infection.

In CPT 2000, however, critical care services are defined as being for the direct delivery by a physician(s) of medical care for a critically ill or injured patient. The introduction goes on to define critical as a condition that acutely impairs one or more vital organ systems such that the patients survival is jeopardized. The services include but are not limited to the treatment or prevention or further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, or overwhelming infection.

Another key change in the CPT 2000 critical care codesand one that directly influences their use in stroke situationsis that physicians can use them for time spent talking to the critical patients family. This is essential in
t-PA treatment because of the time limitation.

Because t-PA can be given only within three hours of the onset of a stroke, the neurologist must make sure he or she finds out when the stroke began. This can be very difficult because the patient may not be able to communicate this information, Soronson explains. Consequently, the neurologist must spend time asking the family about symptoms. This is truly more like critical care than prolonged services, counseling or coordination of care; the neurologist must be a quick detective to find out exactly when the stroke began so treatment can begin (if too much time has not expired).

According to CPT 2000 critical care guidelines, time spent talking to the family when on the floor or unit when the patient is unable or clinically incompetent to participate in discussions can be counted as critical care services. In addition, the new definition provides that time spent on the unit, at the nursing station reviewing test results, discussing the patients care with other staff, and actually documenting critical care services in the record can all be billed using critical care codes. (Neurologists should note that they cannot bill time spent off the unit or floor, even if discussing the patient with the family, as critical care services.)

Neurologists also should be aware that the definition of how time is recorded for the first critical care code (99291) has been revised in CPT 2000. Code 99291 should be used for the first 30-74 minutes of critical care services. If neurologists provide critical care services of less than 30 minutes, they should use the appropriate E/M service code. Code 99292 should be used for each additional 30 minutes beyond the first 74 minutes. It also should be used for the final 15-30 minutes of care on a given date.

Because the t-PA administration usually will be performed on the patients first day in the hospital, neurologists also should bill a hospital admission code (99221-99223probably always 99223 [initial hospital care with comprehensive history, comprehensive examination, and medical decision-making of high complexity], providing the physician has appropriate documentation) as well as the critical care code. But neurologists cannot use the time for the hospital admission in the critical care code. That must be separate from the total critical care time billed because the admission code includes the time associtaed with the patients admission to the hospital.

Tip: Your carrier may have a policy that will not pay for critical care codes the same day as a hospital admission. Consequently, you may have to appeal the denial.

Prolonged Services Coding

Neurologists also can use the prolonged services codes (99356-99357 for face-to-face; 99358-99359 for non-face-to-face) to report time spent with a patient receiving t-PA treatment in addition to the hospital admission code. The physician would base the prolonged service codes on time spent on the patients case, being careful not to include the time for the hospital admission.

Prolonged service codes should be used when the patient is not critically unstable, but the patients care requires an inordinate amount of the neurologists time. These codes are time-sensitive. Codes 99356 and 99358 should be billed for the first hour of care, while 99357 or 99359 should be used for each subsequent 30 minutes of care.

Physicians should not discount the prolonged services codes. They are another level of reimbursement available to neurologists for the t-PA administration.