Neurology & Pain Management Coding Alert

Unbundling coding for two or more procedures that should not be billed together is a major compliance problem. But many neurologists dont understand this concept, which can lead to claim denials. By reviewing the basic ideas behind bundling, such as mutually exclusive and component and comprehensive codes, neurologists can avoid such problems.

By far the largest source of bundling combinations, or edits, is Medicares national Correct Coding Initiative (CCI), which has developed coding policies and more than 120,000 edits for reimbursement compliance to better control improper coding.

Although the CCI has been in place since Jan. 1, 1996, many neurology practices still do not understand its impact on how they bill procedures. This has serious compliance consequences because Medicare auditors may construe billing for procedures bundled into others as fraud. The CCI is particularly important to neurologists because the billing for many of the procedures they perform is guided by its policies. The CCI edits break down into two categories: Mutually exclusive codes and comprehensive/component pairings.

Mutually Exclusive Codes

Mutually exclusive codes represent services that cannot reasonably be performed during the same session. For example, a neurologist cannot perform a nerve conduction study without F-wave (CPT code 95900, nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) and a nerve conduction study with F-wave (CPT code 95903, nerve conduction, amplitude and latency/velocity study, each nerve; motor, with F-wave study) at the same site during the same testing.

Component and Comprehensive Codes

Approximately 11,000, or just less than 10 percent, of the CCIs 120,000 edits are categorized as mutually exclusive. The other 90 percent may be classified roughly as bundlescomprehensive codes that include component codes. Physicians may not bill the component codes if they also charge for the comprehensive procedure.
For example, code 95813 (electroencephalogram [EEG] extended monitoring; greater than one hour) includes 95812 (electroencephalogram [EEG] extended monitoring; up to one hour).

The code 95813 cannot be billed together with 95812, according to the CCI, because the first hour of the EEG (95812) is included in the more complete procedure of 95813. Therefore, the first code is included in the second. CCI further subdivides the comprehensive/component code category according to various principles used to determine the edit. These eight principles include:

1. CPT definition. Some CPT codes are part of a series in which the first code becomes a component for the codes following it that refer back to the common portion of the procedure listed in the preceding entry. For example, 95860 (needle electromyography, one extremity with or without related paraspinal areas) is followed by 95861 (needle electromyography, two extremities with or without related paraspinal areas). If the neurologist performs an electromyogram (EMG) of two extremities, only 95861 may be billed because 95860 is a component of 95861, and is appropriately bundled into that procedure.

2. CPT manual instructions/guidelines. CPT also gives bundling instructions at the beginning of some sections in the manual. For example, in its introduction to codes for neurology and neuromuscular procedures, CPT states that polysomnography (CPT code 95808, polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist) includes a one to four lead electroencephalogram (EEG) and an EMG. It would be inappropriate to bill EEG and EMG codes with the 95808.

3. Sequential procedures. Sometimes neurologists start to perform a procedure and then switch to a more complex procedure (usually because more information is medically necessary). For example, during the same session, the neurologist starts a limited developmental test (96110, developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) but does not obtain enough information. Consequently, he or she performs extended developmental testing by the hour to include an assessment of motor, language, social, adaptive and/or cognitive functioning by standardized instruments (e.g., Bayley Scales of Infant Development) with interpretation and report per hour (96111). In this situation, the more extensive procedure the extended developmental test would be billed, but not the limited test because 96110 is considered to be a component of 96111.

4. Separate procedures. During a manual muscle testing (95831, muscle testing, manual [separate procedure] with report; extremity [excluding hand] or trunk), the neurologist may need to assess the patients range of motion (95851, range of motion measurements and report [separate procedure]; each extremity [excluding hand] or each trunk section [spine]). Because 95851 is a separate procedure, it cannot be billed separately in conjunction with a more comprehensive procedure, in this case, the manual muscle testing.

5. Most extensive procedures. During an electronic analysis of a previously implanted neurostimulator (95970, electronic analysis of implanted neurostimulator pulse generator system [e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements]; simple or complex brain, spinal cord, or peripheral [i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular] neurostimulator pulse generator/transmitter, without reprogramming), the neurologist may need to perform a more extensive procedure. This could include a procedure such as 95971 (electronic analysis of implanted neurostimulator pulse generator system [e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements]; simple brain, spinal cord or peripheral [i.e., peripheral nerve, autonomic nerve, neuromuscular] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming). Because 95971 represents a more extensive procedure than 95970, code 95970 is bundled into 95971.

Judiciously Use Modifiers That Override Bundles

Most CCI edits may be overridden by modifiers to indicate that distinct or independent procedures were performed, and that billing with two codes that normally would be bundled is in fact appropriate because of special circumstances. Modifier -59 (distinct procedural service) was created as a response to the CCI edits and overrides most, but not all, bundling combinations. The CCI uses indicators to show which codes appropriately may use modifier -59 if documentation exists to support the claim that the procedure was distinct (which usually means it was performed on a separate site or at a different time during the same day).

Note: Medicare also has developed its own HCPCS modifiers to indicate procedures were performed on different sites of the body. Two of these modifiers that are most applicable to neurologists are -LT (left side [used to identify procedures performed on the left side of the body or left extremity]) and -RT (right side or right extremity).

Coding combinations when modifier -59 is inappropriate include those in the first category of CCI edits or those that are mutually exclusive. If the codes can be modified, they will have an indicator (1) beside them in the CCI. If they cant, indicator (0) is shown.

Neurologists may bill all the edits in the comprehensive/component category and its subcategories using modifier -59 when appropriate. They should keep in mind that using modifier -59 sends up a red flag for audit, however, so it should be used carefully after ensuring that the appropriate documentation exists to back up the claim.

Note: For complaints about CCI edits, contact the provider relations staff of your local Medicare carrier. To order a copy of the CCI, contact the National Technical Information Service (NTIS) at 1-800-553-6847. The cost of an annual subscription is $260 for hard copy or CD-ROM versions.

Although the CCI is important, it is not the only group of coding edits that Medicare uses. The Health Care Financing Administration (HCFA) instituted many edits before the CCI was established in 1996 and still enforces these. In addition, HCFA purchased a series of edits from HBO&C, which the agency refers to as commercial or proprietary edits, and the rest of the coding world knows as black box edits because they are not published anywhere due to their proprietary nature.

Finally, neurologists should remember that commercial carriers are not bound by and do not necessarily follow the CCI, though they may use it selectively.

Editors note: This article was prepared with the help of Emily Hill, PA-C, a coding and reimbursement specialist in Wilmington, N.C., and a member of the AMAs Correct Coding Policy Committee; Susan Callaway-Stradley, CPC, CCS-P, an independent coding specialist and educator in North Augusta, S.C.; and Catherine Brink, CMM, CPC, owner of HealthCare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J.