Neurology & Pain Management Coding Alert

Modifier -21 can allow you to recoup additional E/M reimbursement when the physician's services don't meet the requirements for prolonged services (99354/99355) - but only if you use it properly.
 
You may append modifier -21 (Prolonged evaluation and management services) only to "the highest level of evaluation and management service within a given category," according to CPT. For instance, you may append modifier -21 to service code 99215 because it is the highest-level established patient outpatient code, but not to codes 99211-99214, says Barbara Johnson, CPC, a coding expert with Loma Linda University Medical Group. So, under what circumstances would you append modifier -21?
 
Take a look at the following example: The neurologist sees a patient who has recently been in an automobile accident. At the time of the accident, the patient did not seek medical attention but has begun to have intermittent back and neck pain. The physician conducts a full history and examination, meeting the requirements to report 99215. The visit lasts one hour.
 
In this case, the patient visit exceeds the time for 99215 by 20 minutes. Although you cannot use a prolonged services code because the time the physician spent with the patient did not exceed 30 minutes beyond the reference time for 99215, you can append modifier -21 to 99215 to gain extra reimbursement for the physician's extended service, Johnson says.

Look to Time-Based E/M as an Alternative

But what if the physician's documentation does not support the highest-level E/M, and the time that he or she spends still exceeds the CPT reference time for the level you choose? You should select an E/M level based on time rather than the components of history, exam and medical decision-making.
 
For instance, a patient who has previously received spinal injections for pain management complains of headaches and visual disturbances in the days following treatment. The neurologist examines the patient. Her documentation supports a level-three office visit (99213), but she documents 30 minutes of face-to-face time. The face-to-face time in this case exceeds the reference time by 15 minutes. You cannot apply modifier -21 or bill for prolonged services. But if the physician spends 50 percent or more of the visit in counseling and/or coordination of care, you may use time - rather than the elements of history, exam and medical decision-making - to select an E/M level, according to CPT.
 
In this example, if we assume the neurologist does spend (and documents) at least 50 percent of the visit in counseling and/or coordination of care, you may report 99214 (which has a reference time of 25 minutes) rather than 99213 for the 30-minute visit.