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Neurology & Pain Management Coding Alert

Here's How to Collect for Apokyn-Related Services

Published on Tue May 24, 2005

Shifting costs to patients may be the only way to avoid losses

If your neurology practice provides Apokyn services for patients with Parkinson's disease, your reimbursement opportunities are generally limited to reporting E/M services.

To be sure to get the pay you deserve for Apokyn-related services, consider three reimbursement solutions.

1. Make the Most of E/M Visits

Because E/M services provide the only opportunity to bill for Apokyn, don't allow poor documentation to diminish the E/M level you can report.

Many Medicare carriers won't cover Apokyn (apomorphine) because the patient can self-administer the drug. But a physician must evaluate the patient prior to prescribing Apokyn. And the patient will usually receive his first injection in the physician office so the physician can evaluate the effectiveness of the drug and watch for any side effects, says Marc Raphaelson, MD, a neurologist in Frederick, Md., and a member of the AAN's medical economics and management committee. These visits represent legitimate reimbursable services.

Look to Level 4 or 5 for Evaluation Visit

The complexity of the E/M service during which the neurologists considers prescribing Apokyn means that you should report a high-level service (for example, 99215, Office or other outpatient visit for the evaluation and management of an established patient ...) for most patients. To claim this service successfully, however, the neurologist must document his work thoroughly.

To determine whether a patient is a suitable candidate for Apokyn, the neurologist must take a thorough history from the patient, says P. David Charles, MD, associate professor, director of the Movement Disorders Clinic and director of the Residency Training Program in Neurology at Vanderbilt University, Nashville, Tenn.

Specifically, the neurologist must determine whether the patient is having sudden, unexpected "off" episodes that affect his daily quality of life. The neurologist must also pay attention to any medication side effects or interactions, as well as any history of cardiac disease or orthostatic hypotension, which requires special caution, Charles says. And the neurologist must determine whether  the patient can tolerate the anti-nausea drug trimethobenzamide, which the patient must take for at least three days before the first dose of Apokyn.

The neurologist's documentation should note not only  the additional time required for such a visit but also the increased levels of history, exam and MDM.
 
Initial Injection Calls for Another High-Level E/M

Once again, when the patient arrives for his "trial" Apokyn injection - and if the neurologist documents his effort - you should report a high-level E/M service.

Administering the patient's first dose of Apokyn is a complex and time-consuming matter, Raphaelson says. "It takes a lot of patient time in the office," he says.

Before administering the injection, the neurologist should review and document the following, which will help support an upper-level E/M service:
 

  • The patient must be in the "off," or immobilized, state (meaning that the patient won't have taken his medications that morning).
     
  • The physician must evaluate how the patient is tolerating the anti-nausea drug and make sure the patient hasn't had any falls or illnesses that could delay treatment using Apokyn.
     
  • The physician re-evaluates concomitant medications to be certain that there have been no new meds that would affect blood pressure or orthostatic responses.
     
  • Because of potential drug side effects, the review of systems (ROS) must document lack of recent chest pain, syncope, or other significant symptoms.
     
  • For patients requiring special attention, including those with prior cardiac disease or orthostatic hypotension, the physician documents review of interim electro-cardiogram (ECG) and other data.
     
  • Following the injection, the neurologist must decide, based on the results of the trial, to prescribe Apokyn (or possibly to schedule a second trial using a higher dosage).

    2. Claim the Injection Code

    For an initial injection of Apokyn given in the neurologist's office, you should report 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular).

    Caution: You should only report 90782 if the neurologist or nurse administers the injection. If the patient self-injects, you cannot charge separately for this service.

    Don't forget: If you are billing 90782 and the E/M service described above at the same patient encounter, you must append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to whichever E/M service code you report.

    Be sure to separately document the injection service from the time spent evaluating the patient prior to injection.

    3. Ask Patient to Supply a Nurse

    The patient must remain in the office suite for evaluation for several hours following the initial injection, and a nurse must be present the entire time.

    Even if you report a level-five E/M service for the visit, you might be losing money after you consider the cost of the nurse's salary and keeping the patient in the office for several hours.

    "Few physicians can afford to absorb the cost of an exam room and a nurse for two and a half hours while only getting paid for an office visit," Raphaelson says.

    Tip: If your office cannot afford to absorb the cost, you might consider asking the patient to hire a nurse from a home health provider. The nurse could accompany the patient to the physician's office for the first dose. That way, the physician is only on the hook for the cost of the suite.

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