Neurology & Pain Management Coding Alert

Choosing the appropriate evaluation and management (E/M) service level is always challenging. Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, N.J., that handles neurology reimbursement, says that a variety of coexisting conditions may accompany a patients presenting complaint. When co-existing conditions and the amount of time spent counseling the patient with or without her family present are not taken into account, a physician may charge for a lower E/M level than he or she should.

Checking for Coexisting Conditions

As physicians know, coexisting conditions may not be immediately apparent. The first indication the neurologist usually receives that coexisting conditions exist generally comes during the history-taking component of the initial patient visit (99201-99205). The information may come from the patient or the patients family.

Within the entire history component, there usually is a chief complaint, history of the present illness, review of body systems or areas, and a past/family/social history.

Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., that consults with several neurology practices, says that the neurologist may uncover a variety of coexisting conditions, such as malignant hypertension (401.0), insulin dependent diabetes (250.01), congestive heart failure (428.0), or respiratory cardiovascular problems during the review of systems portion of the history-taking. The complexity and number of coexisting conditions the neurologist uncovers during the history may dictate how detailed an examination he or she will need to perform, she reports.

The neurologist may choose the appropriate E/M level to bill for the visit in one of two ways. The neurologist may review the documented history that was taken from the patient and family, the exam that was performed on the patient, and the medical decision-making that was needed for this patient and make the choice depending on the severity of the patients complaint and the complexity of the aforementioned three key factors: history taking, examination and level of medical decision-making. The neurologist also may choose to code by time when more than 50 percent of the total visit was spent on counseling and coordination of care for the patient.

Coding for Time

For example, a 70-year-old patient presents with symptoms of memory loss (780.9). If the neurologist met with the patient for 45 minutes, the visit could be coded as a 99204 (office or other outpatient visit for the evaluation and management of a new patient that requires a comprehensive history and examination and medical decision- making of moderate complexity) rather than a 99203 (office or other outpatient visit for the evaluation and management of a new patient that requires a detailed history and examination and medical decision-making of low complexity) provided more than 50 percent of that time was spent in counseling. The neurologist also would need to document what issues were discussed in counseling such as possible treatments, additional testing, prognosis, etc.

Catherine G. Fischer, CPA, reimbursement policy advisor for the Marshfield Clinic, a 650-physician group regional healthcare system with more than 50 specialties including neurology, in Marshfield, Wis., says, Good medical recordkeeping requires that you document all the pertinent pieces of information. Just because you bill by time does not obfuscate documenting history, exam and plan as appropriate. All pertinent medical information needs to be included in the note.

Cobuzzi maintains that neurologists must write down the precise start and stop times of their patient visits in their charts. Brink concurs, stating that the Health Care Financing Administrations (HCFA) guidelines require exact times and that neurologists may run into difficulties if their files are reviewed by the agency and this information is not noted.

Coding for Established Patients

A patient presents displaying symptoms commonly associated with multiple sclerosis (MS, 340), including tingling (782.0), poor balance, difficulty swallowing (787.2), slurred speech (784.5), and dizziness (780.4). The patient may report waking up with vision problems (368.8) and numbness (782.0) and that she has never experienced these symptoms before. In this case a level five initial exam (99205) is not unusual whether it is coded by time (60 minutes spent with the patient) or the comprehensive level of the history and the exam as well as the high complexity of the medical decision-making.

With MS sufferers, a patients symptoms may go into temporary remission, then suddenly reappear. Frequent re-examinations may be necessary. Fischer says that the comp-lexity of the patient encounters will increase as the disease progresses. The course of the disease is not predictable, and each problem that comes up will have to be checked to see if it is the result of the multiple sclerosis or of something else. This may increase the exam time, history taking, decision-making and the time spent counseling the patient.

With an established patient (99211-99215), the neurologist will need to document either two out of the three CPT-required E/M components (history, exam and medical decision-making) or that more than 50 percent of the time in the patient encounter was taken up with counseling. A follow-up visit to review findings for an MS patient will require a great deal of time. The diagnosis, treatment options, and questions from the patient and her spouse all factor into the overall time. This time must be documented appropriately. This is especially important with MS patients or others who must be referred to numerous other specialists.

Time spent in counseling is a variable that can create the entire level of service for the physician, states Fischer. Provided that time spent in counseling is the majority of the service, it well may override all other considerations.

Neurologist should note that they cannot count the time spent in taking the patients history or performing an examination as counseling time. The neurologist must look at the entire patient encounter and decide if the majority of time was spent in counseling and coordination of care or if the other three components should be the deciding factor when choosing an E/M level.

Whichever method gets you to the appropriate higher level is what you should use, says Fischer.