Neurology & Pain Management Coding Alert

Neurologists frequently see patients in the emergency room (ER) and subsequently admit them as inpatients. The ER visits that precede hospitalizations can be extensive; even hours long. In general, however, a neurologist will be reimbursed only for either the ER visit or hospital admission, if they both occur on the same day.

You cant bill for two evaluation and management (E/M) codes on the same day. Most carriers will only pay for one, so most practices choose the code that has the higher reimbursement. Thats usually the inpatient history and physical, explains Barry Haitoff, president of Medical Management Corporation of America, a billing and management firm in Brewster, N.Y.

According to CPT 2000, the initial hospital care code includes any care provided elsewhere on that date: When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital, physicians office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are consider part of the initial hospital care when performed on the same date as the admission.

Neurologists should consider, however, the work done in the emergency room when determining which level code to use for the admission. As CPT 2000 states, the inpatient care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of services as well as in the inpatient setting.

The good news is that, usually, there is overlap between the ER examination and the examination, history and decision-making associated with the inpatient admission. When a neurologist goes to the ER, much of the work done there ties into what they need for the hospital admission, says Gail Levy, a consultant with ADB Associates, a healthcare reimbursement consulting firm based in Baltimore.

Knowing Which Inpatient Codes to Use

Which of the three hospital care codes 99221, 99222 or 99223 is appropriate, then? (See Inpatient Hospital Care Codes below.)

Medical decision-making is what drives the difference between the codes because youre already required to do detailed or comprehensive history and examinations at the lowest level, explains Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based coding and reimbursement firm.

The three elements of medical decision-making include:

1. Mortality and morbidity. What are the risks of significant complications, death or comorbidities associated with the patients presenting problems, diagnostic procedures and/or possible management options?

2. Diagnosis and management options considered. How complex is the differential diagnosis? How many possible treatment options are there?

3. Records and tests reviewed. How many and how complex are the tests and medical records that have to be reviewed and analyzed?

To use 99223, the highest inpatient care code, two of the three above criteria must be complex. An example from CPT 2000 is: An initial hospital visit for a one-year old male victim of child abuse with central nervous system depression, skull fracture and retinal hemorrhage.

Still, a neurologist may want a return on the considerable time invested between the ER visit and hospital admission. Taking into account the time spent is not wrong, but CPT includes a disclaimer that the time periods associated with E/M codes are only averages. If you use time as the level determinant, then more than 50 percent of your time must be spent counseling and coordinating care face to face with the patient and/or family, Parman advises.

The Problem With Same-day ER and Inpatient Claims

Some neurologists may ask why they cant file a claim for the ER visit to report that activity, even though it wont be reimbursed? Medicare frowns on it. They see billing things that you know are not covered as an abusive practice, and they have started sending out cease-
and-desist letters that say Its costing us money to deal with you. Parman explains.

Levy agrees. If the carrier has made it clear that they dont want you to do it and you do, it could put you in the situation of abusive billing. Most wont pay for more than one E/M service for one day, so if you separately bill for the ER visit and admission its almost unbundling because of the standard practice in the industry, she says.

Use Prolonged Services and Consult Codes

One approach to billing for a three-hour long ER visit followed by an admission would be to use 99223 in conjunction with the extended inpatient service codes, 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour) and 99357 (each additional 30 minutes of prolonged physician service in the inpatient setting). But even after subtracting the ER-specific activities from the overall time, you might still face review from the carrier, advises Mary Hensley, administrator of the department of neurology at the University of Iowa in Iowa City.

Those prolonged service codes are generally subject to review, so you would have to have very clear documentation. Sequencing of the codes might also be an issue, she adds.

Another approach might be to use 99223 along with the codes for prolonged physician service without direct (face-to-face) patient contact: 99358 (prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; first hour); and 99359 (each additional 30 minutes). These codes can be used in the in- or outpatient setting, and before or after face-to-face time with the patient, so the sequencing is not an issue, Hensley says.

If the patient is not admitted, then the ER visit codes (99281-99285) or consultation codes (99241-99245) might be used.

Inpatient Hospital Care Codes 99221 Initial hospital care, per day, for the evaluation and management of a patient which requires a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision-making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs.Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patients hospital floor or unit. 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs.Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patients hospital floor or unit. 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patients hospital floor or unit.