Neurology & Pain Management Coding Alert

Diagnostic testing forms the core of neurology practice. Because such testing assumes that a definitive diagnosis has not been determined, assigning ICD-9 codes can prove frustrating. Although recent changes to CMS guidelines have given neurologists more options for reporting posttest diagnoses, the best solution is to note carefully the patient's chief complaint and all related signs and symptoms. Documentation of this type supports the neurologist's CPT coding by showing medical justification, leading to better patient care and fewer claim denials.

If the diagnosis(es) linked to a particular procedure or service cannot sufficiently explain why that procedure or service was reasonable and necessary, the claim will likely be rejected. Although many diabetics have neuropathy, a diagnosis of only diabetes (250.xx) will not support diagnostic testing for neuropathy.

Without a definitive diagnosis, you should use signs and symptoms codes to show that the patient has a problem that requires further investigation and to provide justification for diagnostic testing, says Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., a healthcare consulting firm in Dallas, Ga. Generally, the more signs and symptoms that can be documented as long as they pertain to the current problem the better. Signs and symptoms codes are found primarily in Chapter 16, Volume I of ICD-9 ("Symptoms, Signs, and Ill-Defined Conditions," 780-799), although there are exceptions (e.g., 729.5, Pain in limb).

In the example of the diabetic patient, symptoms such as loss of coordination (781.3), numbness and tingling (782.0) or pain in the feet (719.47) suggest that neuropathy may be present and that further testing, such as nerve conduction studies (NCS) or electromyography (EMG), is reasonable and necessary. Regardless of the results of testing, the tests should be reimbursed because medical necessity was demonstrated.

Except in very limited circumstances (e.g., preoperative screenings), Medicare will not pay for screenings even if the test reveals a problem that requires further treatment. By definition, a screening involves testing or examination without direct medical evidence (signs and symptoms) that such services are necessary. In these cases, you should report the reason for the test (e.g., V80.0, Special screening for neurological conditions) as the primary diagnosis. The results of the test, whether negative or positive, may be recorded as additional diagnoses. For example, if you perform a screening for CTS and the results come back positive, you may report 354.0 as an additional diagnosis (with V80.0 as the primary diagnosis).

Similarly, physicians in private practice should avoid "suspected" or rule-out diagnoses. For example, a patient visits the neurologist complaining of numbness, dryness and "coldness" in the left wrist. In addition, the patient's history reveals that his or her work involves many hours per day of repetitive motion (typing), and the primary care physician has already referred the patient for a possible diagnosis of carpal tunnel syndrome (CTS). To gather more information, the neurologist orders a combination of EMG (95860, Needle electromyography, one extremity with or without related paraspinal areas) and NCS (95900-95904, as appropriate). Although the neurologist is in fact relying on the diagnostic tests to confirm or rule out a suspected diagnoses (354.0), he or she must report signs and symptoms codes, such as 719.44 (Pain in joint, hand), 726.4 (Enthesopathy of wrist and carpus) and 782.0, to justify the testing.

Never report an unconfirmed diagnosis in an attempt to justify billing procedures or services, regardless of how definitive the diagnosis appears to be. This unfairly labels the patients as having a condition that they may not, in fact, have. Insurers maintain databases of all these codes, and if the patient later applies for life, health or disability insurance, the insurance company will look for any problems he or she may have had in the past. "The diagnosis selected when ordering a diagnostic test should be substantiated by the information in the physician's documentation," says Bruce H. Cohen, MD, co-director of the Brain Tumor Center at the Cleveland Clinic Foundation in Cleveland. Similarly, you cannot make up signs and symptoms "after the fact" in an attempt to justify services rendered.

The neurologist is treating a patient with generalized convulsive epilepsy (345.11) that has not responded to medication. Concerned that the patient may suffer from additional problems, such as an aneurysm (747.81), the neurologist wishes to conduct additional testing. When ordering a CAT scan for this patient, the neurologist should not report 747.81 as a diagnosis because the condition has not been proven. Rather, the neurologist should rely on the epilepsy diagnosis and other related signs and symptoms.

On Sept. 26, 2001, CMS released transmittal AB-01-144, clarifying a long-standing debate on whether physicians should report a suspected diagnosis confirmed by diagnostic testing as the reason for the testing itself. Effective Jan. 1, 2002, the transmittal allows this practice, specifically stating, "If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis.

The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis."

Using the example of the patient with suspected CTS, the neurologist may record 354.0 as the primary diagnosis if the EMG and NCS confirm the presence of CTS. If testing is inconclusive or does not support a finding of CTS, signs and symptoms (e.g., 719.44, 726.4, 782.0) may still be used to provide medical justification for testing.

Signs and symptoms can also justify higher E/M levels. The medical decision-making (MDM) portion of the E/M services may be more complex when the neurologist must select a differential (suspected) diagnosis from several possibilities. Patient risk and the number of tests ordered and reviewed are also likely to be higher when a specific diagnosis is not confirmed, Cohen suggests. An undiagnosed problem often means the physician must order several tests to determine a diagnosis. Considering all these factors may increase the E/M service by one or more levels.

A diabetic patient with suspected neuropathy is referred to the neurologist for diagnostic testing. During the exam, the patient has signs and symptoms (e.g., 787.02, Nausea; 787.01, with vomiting; 787.03, Vomiting; 789.06, Abdominal pain, epigastric; etc.) suggestive of gastroparesis (536.3), a neuropathy-related gastrointestinal (GI) disorder. For a diabetic, gastroparesis is especially serious. Oral medications may never reach the bloodstream. Insulin injections are impossible to schedule because the patient cannot predict when or if meals will be digested, increasing the risk of hypo- and hyperglycemia.

In this case, MDM plays a major role in selecting the appropriate E/M code. The regularity of GI problems among diabetics provides many possible diagnoses for patients complaining of gastroparesis-like symptoms, thereby raising the level of decision-making. In addition, the need to seek advice from other specialists is another indicator of the complexity of diagnostic or management problems. For diabetics with a potentially life-threatening complication, perhaps the most important factor to consider is medical risk. In the case of gastroparesis, there is a moderate-to-high risk of complications and/or morbidity or mortality for a diabetic patient, depending on the condition's severity.

Considering all the criteria of history (comprehensive), exam (comprehensive) and MDM (high-complexity) for the diabetic patient in the above example, the service qualifies as a level-five office visit (99205). Appropriate ICD-9 coding is crucial: Without a primary diagnosis of diabetes (e.g., 250.9x, Diabetes with unspecified complication), signs and symptoms such as vomiting and nausea cannot substantiate a high level of risk to the patient, and therefore cannot provide medical justification for an extensive E/M service. Likewise, an established diabetes diagnosis, absent of signs and symptoms of potentially serious complications, does not warrant a comprehensive history, detailed exam and high-complexity MDM. Because the diagnosis of gastroparesis is unconfirmed, however, it should not be reported.