Neurology & Pain Management Coding Alert

The new ambulatory payment classification (APC) regulations set forth by the Health care Financing Administration (HCFA) will soon take the thousands of codes that are used for outpatient services and consolidate them into a smaller group of 451 APCs. This new programs effective date has changed from July 1, 2000, to Aug. 1, 2000.

These new payment groups will take into consideration every aspect of outpatient care, including usage of medical supplies, staffing efficiencies, and several other operational costs. Further, coders will be required to use them in outpatient clinics, emergency departments, diagnostic radiology, respiratory therapy, and ambulatory surgery centers. According to HCFA estimates, these codes will result in a potential 4.6 percent average increase in Medicare payments for hospitals and outpatient facilities.

How Reimbursement Is Affected

The APCs will not directly impact the way neurologists and other Part B providers code and bill services for Medicare patients. This is true even if the hospital is doing the neurologists billing. There are ways, however, in which the neurologist may be affected.

Jack Turner, MD, PhD, medical director for documentation, coding and compliance with Team Health, a physician staffing company in Knoxville, Tenn., says that if hospitals and outpatient facilities begin to lose money on certain procedures or services, they may no longer make them available and that will affect the neurologists potential earnings and ability to provide the best possible care to his or her patients.

What we have to recognize is that what we write on a chart, what medications and tests we order, and what procedures we perform will now greatly influence the bottom line of the hospital, Turner says. We have to be concerned about how the hospital will fare with this new system of reimbursement. The physician who is performing outpatient procedures needs to consider the well-being of the hospital as well as the well-being of the patient. If the hospital does not get paid, they are going to suffer, and ultimately, that affects where we are going to perform our procedures and what procedures we perform.

Catherine A. Brink, CMM, CPC, president of Healthcare Resources Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., that consults with several neurology practices, reports that neurologists writing chart documentation for outpatient procedures such as electromyograms (EMG, 95860-95872), nerve conduction studies (95900-95904), epidural blocks (62310-62319, 64479-64484), and any other procedures performed on Medicare patients at a hospital or outpatient facility will have to be extremely accurate and extensive for hospital and outpatient facility coders to bill properly.

For example, a common outpatient procedure performed by neurologists is 95925 (short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system, in upper limbs). If the neurologist simply indicates motor nerve test in his or her chart notes, the hospital coder may erroneously bill this as a 95900 (nerve conduction study, amplitude and latency/velocity study; each nerve; motor, without F-wave study), and the bill will be placed under APC 215, which pays $55.76. The correct code, however, 95925, is part of APC 216, which pays $139.16. The neurologist who does not clearly indicate the exact service performed may, in this case, cause a loss of reimbursement of $83.40.

Documentation Is a Critical Key

According to Brink, the APCs will require hospitals and outpatient facilities to code and bill in an entirely new way. From a physicians point of view, when a neurologist performs a procedure in a hospital or outpatient facility for a Medicare patient, he or she will continue to bill for the professional component of that procedure with the Medicare Part B HCFA 1500 form, exactly as before.

Under the APCs, however, all of the hospital or outpatient facilitys charges for the technical component of the procedure have to be consolidated into one bill, meaning that the it cannot be submitted for reimbursement until every department submits its portion to central billing, and that bill is itemized and correctly coded. All applicable nursing services, x-rays, medications and treatments performed by hospital staff (such as injections), along with charges for the room itself, equipment, disposable items, etc., are listed all at once on a line item basis on the Medicare Part A UB92 form.

Further, the hospital or outpatient facility coder will have only one opportunity to submit a bill; Medicare will not accept late or ancillary billing. Now, more than ever, the hospital needs the help of the neurologist with precise and comprehensive chart documentation.

According to a June 2000 report to Congress by the Medicare Payment Advisory Commission (MedPAC), The new payment system gives hospitals an incentive they previously lacked to code visits accurately. This is because codes that seem similar in scope may belong to different APCs. For example, if a neurologist performs a needle electromyography, three extremities (95860 and 95861) and bills it using one of these first two codes, it will be grouped into APC 215 (level I nerve and muscle tests), which pays $55.76. The proper code, however, 95863, is actually a part of APC 216 (level II nerve and muscle tests), which pays $139.16.

Proving Medical Necessity Is Key

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, a coder who specializes in neurological procedures, recommends that neurologists and coders pay more attention to diagnosis coding, which will be even more important to document the medical necessity for a procedure. Also, what will prove to be most important for billing is the coordination between the neurologist and the hospital. The responsibility for the billing and the coding will fall on the hospital.

But, as Brink is quick to remind neurologists, documentation will have to be extremely accurate and extensive for the hospital coders to be able to bill properly. The neurologists documentation is going to have to back up the intensity and the medical necessity for the procedure codes charged. If the documentation is lacking, the hospital will have a problem proving the need for the procedure.

Dealing With Hospital and Emergency Departments

Sandham reports that neurologists who do consultations in emergency room settings are going to be dealing with patients who receive a great deal of ancillary services, and the neurologist will need to be attuned to whatever final interpretations of these guidelines Medicare establishes. The intensities of the services that neurologists provide in an outpatient basis will be reflected in how the hospital ultimately can describe that service.

Hospitals will respond to this new program by developing more efficient outpatient treatments and coordinating better with their neurologists on patient encounters. Hospitals will have to compare what the procedures cost and what their reimbursement will be under APCs. Hospitals will be looking to find ways to do procedures cheaper and to save money on the basic care. Outpatient service providers will need to find ways to use personnel more efficiently as well.