Neurology & Pain Management Coding Alert

Choosing the right CPT procedure code is the first step to ensure your neurologist gets paid for the work she does, but if you fail to attach the correct diagnosis code, you may be in jeopardy of receiving denials.

Follow these expert recommendations to ensure you-re properly coding patients- signs, symptoms and diagnoses -- and keeping your claims on track.

Correct coding requires that you code as specifically as possible. That means your physician should assign the most precise ICD-9 code to a service. You cannot justify a service with a four-digit diagnosis code when carriers or ICD-9 requires a more specific five-digit code to describe the patient's condition.

"Using the fourth or fifth digit when it is required -- or just when you do have that information -- is an important concept to follow," says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla. Make sure you review the entire record when determining the specific reasons for the encounter and the conditions the physician treated, she says.

Pitfall: Don't assume symptoms that aren't in the medical record. For example, if you-re coding for a stroke patient, you cannot simply report 434.0 (Occlusion of cerebral arteries; cerebral thrombosis) because four digits alone don't provide a complete diagnosis.

You must include either "0" or "1" as a fifth digit to indicate whether the physician mentions cerebral infarction. But you also cannot assume the patient has high blood pressure and include a code for it unless the physician includes a diagnosis in the patient's chart. Follow your physician's documentation when selecting diagnoses.

Tip: If the medical record does not allow you to code to the required level of specificity, check with the reporting physician for guidance.

When your neurologist provides a confirmed diagnosis, you should always code that diagnosis instead of the presenting signs and symptoms. If the physician cannot document a definitive diagnosis, however, report the patient's signs and symptoms to support medical necessity for services your physician provides.

Avoid "rule outs": ICD-9 coding guidelines state that you should not report "rule-out" diagnoses in the outpatient setting. You-ll avoid labeling the patient with an unconfirmed diagnosis, and by coding the presenting signs and symptoms, your neurologist will still get paid for his services, even if he cannot establish a definitive diagnosis.

"Look to see if the physician has given the patient a definitive diagnosis," says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, Mich. "-Rule out,- -suspected,- -probable- or -questionable- are not codeable. If there is no definitive diagnosis given, look for any signs or symptoms that the patient has been having."

Again: CMS outpatient services guidelines explicitly state that practices should not use the condition being ruled out as the diagnosis. Instead, "code the condition(s) to the highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results ..."

Pointer: Talk to your physicians about how important accuracy with their terms is. Tell the physician that if she can come to a definite conclusion about the patient's

diagnosis, she needs to state this in her dictation so you may choose the best code.

Coders might hesitate to report V codes, but sometimes this section of ICD-9 most accurately describes the reason for the patient's visit. Actually, you should use V codes to provide additional clinical information to an insurer, whether it's Medicare or a private carrier.

Most coders believe that V codes are appropriate only as secondary diagnoses, but the reality is that you may -- and on occasion should -- report V codes as a primary diagnosis. In some instances, a V code may even be the only way to be paid for a service.

How you know: Many versions of the ICD-9 manual indicate whether you can report a V code as a primary or secondary diagnosis using the designations "PDx" (primary) and "SDx" (secondary) beside the code descriptor.

Example: You can report V68.1 (Issue of repeat prescriptions) as a primary diagnosis, but only submit V58.64 (Long-term [current] use of non-steroidal anti-inflammatories [NSAID]) as a secondary diagnosis.

If the V code has neither a "PDx" nor an "SDx" designation, you may use it as either a primary or a secondary diagnosis, according to ICD-9 instructions.