Neurology & Pain Management Coding Alert

CPT 2002 was made available in November 2001. In an early release of new and revised codes, the AMA has a preview of changes for the upcoming year. Changes affecting neurology are few, and generally serve only to clarify or narrow previous definitions. In most cases, the revised descriptors do not affect how the codes are applied.
 
Although only time will tell how CMS and private payers will respond to the revisions, you should begin preparing now for the changes. CPT 2002 is officially effective Jan. 1, 2002, but not all payers adopt changes uniformly. Check with your carrier before billing any of the revised codes outlined below.
  
Lumbar Puncture

The descriptor for 62272 has a slight revision (new text has been bolded):

62272 spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter).
 
Previously, the descriptor less specifically indicated "for drainage of spinal fluid."

For greater clarity, 78615 now specifies "vascular flow" rather than "blood flow."

78615 cerebral vascular flow.
 
Likewise, neuroimaging code 78560 drops the abbreviation "CSF" in favor of  "cerebrospinal," without affecting use of the code.
 

78650 cerebrospinal fluid leakage detection and localization.

In a change similar to that affecting 78650, infusion code 90780 drops the abbreviation "IV" for "intravenous."
 

90780 intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour.
 
This change does not alter application of the code, and physicians should continue to assign 90780 with caution. Specifically, documentation of physician presence during the infusion is required, says Carol Pohlig, BSN, RN, CPC, who works in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. To meet the requirement for "direct" supervision, the physician must be present in the office suite (although not necessarily in the same room) and immediately available to instruct or assist.

The phrase "or mixed" has been eliminated from the descriptor for nerve conduction study (NCS) code 95904:
 

95904 nerve conduction, amplitude and latency/velocity study, each nerve; sensory.
 
Of all the changes, this is perhaps the most important for neurologists. "This is a huge issue, even though the wording change seems slight," says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology at the University of Pittsburgh School of Medicine. "Because of the wording change, improper bundling of motor with sensory nerve conduction studies will no longer be as likely to occur. This will dramatically decrease the hassle inflicted on physicians doing EMG/NCS under the current definitions."
 
Until now, some insurers (and providers) did not understand what constituted a "mixed" NCS and inappropriately assumed that 95904 was used to bundle motor and sensory studies. As a result, reimbursement was provided for only one study per nerve rather than for each separate motor and sensory NCS. However, mixed NCSs are separate and distinct from both sensory and motor studies, and should be reimbursed as such.
 
According to information on the American Association of Electrodiagnostic Medicine (AAEM) Web site (http://www.aaem.net), sensory NCS (94904) involves stimulation of sensory fibers only, with recording on a different site along the same nerve, or stimulation of a nerve containing motor and sensory fibers while recording over a purely sensory branch of the same nerve.
 
By contrast, a motor NCS involves stimulation at various points along a motor nerve containing motor fibers. The response is recorded from a muscle innervated by those fibers. Such tests are billed using 95900 (nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) and/or 95903 (... motor, with F-wave study).
 
A mixed NCS involves the stimulation of a nerve containing both motor and sensory fibers, i.e., a "mixed" nerve, and recording from a different location (also containing motor and sensory nerve fibers) along the same nerve. As stated on the AAEM Web site, "The resulting record is a mixed nerve action potential that represents activity in both motor and sensory nerve fibers."
 
Despite the change in definition, a true mixed NCS (as described above) will still be reported using 95904 "by agreement," Busis says, i.e., when recording from a muscle, report 95900 or 95903, as appropriate. When recording from a nerve, report 95904.

Electromyography

Code 95875 has undergone considerable revision:
 

95875 ischemic limb exercise test with serial specimen(s) acquisition for muscle metabolite(s).
 
Previously, the code descriptor specified " with needle electromyography, with lactic acid determination." Busis says the code was revised because most physicians do not perform EMGs during the test.

Chemotherapy administration code 96450 now more generally specifies "spinal puncture" instead of "lumbar puncture":
 

96450 chemotherapy administration, into CNS [central nervous system] (e.g., intrathecal), requiring and including spinal puncture.

The descriptors for care plan oversight services (99374-99379) have been revised to clarify with whom the physician may coordinate care (new text has been underlined):
 

99374 physician supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (e.g. Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), and surrogate decision maker(s), e.g., legal guardian(s) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes.

The codes for hospice and nursing facility patients (99377 and 99379, respectively) have been similarly revised.

To reduce the use of unlisted-procedure codes, i.e., 95999, unlisted neurological or neuromuscular diagnostic procedure, CPT 2002 includes a host of new neurology codes as well as a number of new "home care" codes that may be applied by neurologists. Precisely how these codes will be applied, the reimbursement they will allow (per the 2002 physician fee schedule and insurer guidelines) and whether CMS and private payers will accept them remains to be seen. Look to future issues of Neurology Coding Alert for more information.
 

95965 magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (e.g., epileptic cerebral cortex localization)
 

95966 for evoked magnetic fields, single modality (e.g., sensory, motor, language, or visual cortex localization)
 

95967 each additional modality (e.g., sensory, motor, language, or visual cortex localization) (list separately in addition to code for primary procedure)
 

96000 comprehensive computer-based motion analysis by video-taping and 3-D kinematics
 

96001 with dynamic plantar pressure measurements during walking
 

96002 dynamic surface electromyography, during walking or other functional activities, 1-12 muscles
 

96003 one muscle
 

96004 physician review and interpretation of comprehensive computer based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report
 

99506 home visit for intramuscular injections
 

99508 home visit for polysomnography and sleep studies
 

99539 unlisted home visit service or procedure
 

99568 home infusion of miscellaneous drugs, per diem
 

99569 home infusion, each additional therapy given on same day (list separately in addition to code for primary visit).

Two modifiers have undergone changes in CPT 2002. Modifier -60 (altered surgical field) was introduced in CPT 2001. At that time, the full descriptor for modifier -22 (unusual procedural services) in Appendix A of CPT was revised to state, "This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and or alteration of normal landmarks due to late effects of prior surgery, irradiation, injection, very low weight (i.e., neonates and infants less than 10 kg) or trauma." In a Dec. 21, 2000, transmittal (B-00-75), CMS refused to recognize modifier -60, claiming that it lent itself to abuse and was difficult to verify. With that decision, modifier -22 again became appropriate for the above-listed conditions.
 
For 2002, modifier -60 has been deleted and the full descriptor for modifier -22 has been revised. In practice, these changes do not alter CMS policy. Continue to apply modifier -22 for services greater than those usually required for the service/procedure to which it is appended (including cases of an altered surgical field, when appropriate). As before, careful documentation and a request for additional compensation commensurate with the additional effort and/or time necessary to complete the service or procedure are required, e.g., a 30 percent fee increase for a procedure that required 30 percent additional time or effort. Be sure to file a "paper" claim when reporting modifier -22, Pohlig reminds. The insurer will want to review the medical record.
 
Note: All physician practices are strongly encouraged to purchase an updated CPT manual each year. For more information on all editions of CPT, as well as HCPCS and ICD-9 manuals, contact the AMA at 800-621-8335 or visit the association's product Web site at http://www.ama-assn.org/catalog.