Neurology & Pain Management Coding Alert

The American Medical Associations (AMA) CPT changes for 2001 indicate a more straightforward approach for coding many neurological procedures such as botox injections and computed tomography (CT) and magnetic resonance (MR) scans.

The AMA has changed a lot of wording for clarification and added some important codes, explains Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based billing and reimbursement firm. The modifications outlined in CPT 2001 will take effect Jan.1, 2001, for Medicare, although it may take longer for other carriers to adopt them. Parman advises coders to work closely with carriers to determine when to begin implementing the new codes. It is never too early for coders to begin brushing up on the revisions and some of the relative changes are outlined below.

New Chemodenervation Code

Neurology providers who use botulinum toxin (botox) injections to treat spastic muscle disorders should be pleased with the introduction of a new code for injections to the extremities and/or trunk muscles. Neil A. Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at UPMC Shadyside in Pittsburgh, states that the AMA created the new code because there were no specific codes designated for chemodenervation to the extremities.

Many experts feel that the creation of 64614 necessitated the accompanying change in 64612 (chemodenervation of muscle[s];muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]). The words chemodenervation of muscle end plate have been replaced with chemodenervation of muscle, which is a more accurate statement of the procedure.

The new definition for 64614 is chemodenervation, extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis).

The code does not include needle electromyograms (EMGs), nerve conduction studies, or the medicine itself. As before, the botox should be coded using J0585.

Computerized Tomographic Angiography Codes

According to Busis, the new computed tomography angiography codes are a benefit because they will encourage institutions to perform this procedure. These new codes give institutions an additional choice for what kind of angiogram they will perform on a patient.

The new codes are as follows:

70496 computed tomographic angiography, head, without contrast material(s) and further sections, including image post-processing; and

70498 computed tomographic angiography, neck, without contrast material(s), followed by contrast material(s) and further sections, including image post-processing

As there were no specific codes (and no direct route to gain reimbursement) for CT angiography prior to CPT 2001, many neurologists were hesitant to perform these procedures. Now that these codes have been assigned, neurologists can perform these procedures with much greater confidence that they will be reimbursed.

Magnetic Resonance Angiography Codes

Neurology coders will also have new MR angiography codes. The significant change here is that CPT has separated the head from the neck and created six codes, where before there was only one, explains Gary Dorfman, MD, FACR, FSCVIR, past president of the Society for Cardiovascular and Interventional Radiology and president of Health Care Value Systems in North Kingstown, Pa., which provides practice management services as well as revenue optimization techniques through coding and billing support There will be two classifications, one to address each anatomical area, and each category will have three specific MR angiography codes within it describing with, without and without followed by with contrast.

Dorfman states this is a significant step forward. MR angiography of the head and of the neck are separate procedures. If a patient has a cerebral vascular accident (CVA or stroke), for instance, you may want to conduct MR angiography of the brain and then, later, conduct a study of the neck vasculature. These are completely different studies.

The new codes for the head are as follows:

70544 magnetic resonance angiography, head; without contrast material(s),

70545 with contrast material(s), and

70546 without contrast material(s), followed by contrast material(s) and further sequences

The new codes for the neck are as follows:

70547 magnetic resonance angiography, neck; without contrast material(s),

70548 with contrast material(s), and

70549 without contrast material(s), followed by contrast material(s) and further sequences

MRI Contrast Codes

Change can also be found in the magnetic resonance imaging (MRI) codes, Parman adds. All MRI studies will be coded with the same methodology used for the CT codes. Codes have been added so MRIs will have a code for with, without and without followed by with contrast materials.

They are as follows:

70540 magnetic resonance (e.g., proton) imaging, orbit, face, and neck; without contrast material(s),

70542 with contrast material(s); and

70543 without contrast material(s), followed by contrast material(s) and further sequences.

Therapeutic Procedures

Code 97532 describes a focus of therapy required for adults with diagnoses of psychiatric disorders and brain injuries. Code 97533 is a technique used with pediatric patients to enhance sensory processing when the patient suffers from conditions that cause these deficits. Conditions include autism (299.0) and cerebral palsy (343.0-343.9). New therapeutic procedure codes include:

97532 development of cognitive skills to improve attention, memory, problem solving, includes compensatory training, direct patient contact by the provider, each 15 minutes; and

97533 sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct patient contact by the provider, each 15 minutes.

Fluoroscopic Guidance Codes

CPT 2001 also updates guidance codes to add consistency among fluoroscopic and MR guidance. Code 76003 will be modified to read fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), which is used as fluoroscopy guidance for procedures such as vertebral biopsies (20225). A new code, 76393 (magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration, injection, or placement of localization device], radiological supervision and interpretation) has been added to reflect the use of MR to guide needles during procedures such as 20225.

Additional New and Revised Codes

Code 64630 (destruction by neurolytic agent; pudendal nerve) has been revised to make the pudendal nerve its own category. This will enable neurologists to bill separately for the destruction of a peripheral nerve or branch of the pudenal nerve; previously, the code for the pudenal nerve branched from code 64622 (destruction by neurolytic agent, paravertebral facet joint nerve). Now 64622 and 64630 can be billed separately.

Code 92585 (auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive) has been revised to include the word comprehensive, and new code 92586 (... limited) has been created. This enables neurologists to differentiate in billing for a comprehensive versus a limited test.

Changes to Critical Care Services

Revisions to critical care code definitions have also been added. These additions clarify when the critical care codes are appropriate and what can be billed along with these codes. Busis reports that the changes will impact neurologists because much of what they do is consultative. Neurologists get reimbursed for consultations by using critical care codes.

For example, the t-PA code 37195 (thrombolysis, cerebral, by intravenous infusion) is not a code that neurologists would use because it involves giving the material. The neurologist receives reimbursement for the evaluation and management (E/M) services that go along with administering the medicine, observing while the medicine is given, and following up afterwards. The critical care codes are particularly appropriate with t-PA administration (generally used for stroke victims). The additions include, but are not limited to, the following text:

Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life-threatening situations when these elements are not present.

Providing medical care to a critically ill, injured, or postoperative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Critical care and other E/M services may be provided to the same patient on the same date by the same physician.

Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.

Care Plan Oversight Codes

Because CPT 2001 changed the language for its Care Plan Oversight E/M codes (99374-99380) to include language about non-physician professionals, the Health Care Financing Administration (HCFA) has chosen to introduce new G codes for billing these services, and has stated that they will no longer accept 99375 and 99378 (physician supervision of home health or hospice patients, 30 minutes or more).

According to the Final Rule, CPTs revised definitions for 99375 and 99378, which refer to communication (including phone calls) with other healthcare professionals and other non-physician professionals involved in the patients care are inconsistent with Medicare policies.

The Final Rule states, While we recognize that non-physician professionals contribute to the care of both home health and hospice patients, our long-standing policy has been that payment for these services is included in the payment for E/M services ... It was always our intent to count the time spent with other health professionals toward the 30-minute threshold. We feel the revised definitions of 99375 and 99378 necessitate the establishment of temporary HCPCS codes G0181 and G0182 to assure consistency with current Medicare policy.

HCFA has introduced the following codes:

G0181 physician supervision of a patient under care of Medicare-covered home health agency (patient not present) requiring complex and multidisciplinary care modalities; and

G0182 physician supervision of a patient under care of Medicare-covered hospice (patient not present) requiring complex and multidisciplinary care modalities.

Under the new fee schedule, physicians will receive separate payment for certifying and recertifying that patients are eligible for Medicare home health services. Previously, these services were included in the physicians E/M codes, but HCFA is now introducing new HCPCS codes for certification and recertification of home health services to emphasize the importance of physician involvement in home health services under the new home health prospective payment system:

G0180 physician services for the initial certification of Medicare-covered home health services, for a patients home health certification period; and

G0179 physician services for the recertification of Medicare-covered home health services, for a patients home health certification period

These codes can be billed only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapse and requires a new plan of care.