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 [...]