Neurology & Pain Management Coding Alert

Boost your E/M -- and reimbursement -- with stellar documentation

The Food and Drug Administration approved apomorphine hydrochloride (Apokyn) injection use in 2004, but HCPCS didn't include a code for the drug until 2007. If your neurologist provides Apokyn services for patients with Parkinson's disease, check out our experts- advice on how to code the encounters.

E/M services provide the only opportunity to bill for Apokyn injections, but that doesn't mean you can't get appropriate reimbursement for your physician. Stellar documentation can help justify higher-level E/M codes for these visits when your neurologist provides expanded services.

Hang up: Many Medicare carriers won't cover Apokyn 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 neurologist can evaluate the drug's effectiveness and watch for any side effects, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, RCC, CodeRyte Inc. coding analyst and coding review teacher. These visits represent legitimate reimbursable services.

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

First steps: 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, Movement Disorders Clinic director and neurology residency training program director at Vanderbilt University in Nashville, Tenn.

Specifically, the neurologist must determine whether the patient is having -off- episodes that don't respond to medication or other typical treatments, and that truly impact his daily quality of life (muscle stiffness, difficulty starting movement, slow movements). 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.

Details count: The neurologist's documentation should include the additional time required for such a visit, plus the increased levels of history, exam and medical decision-making (MDM).

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, Charles says. -It requires expertise in Parkinson's drug treatment and sufficient time for patient evaluation and education.-

Checkpoint: 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 verify that the patient hasn't had any falls or illnesses that could delay Apokyn treatment.
• The physician re-evaluates concomitant medications to be certain the patient isn't taking medications that would affect blood pressure or orthostatic responses.
• Because of potential drug side effects, the review of systems (ROS) must document the patient's 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 his review of interim electrocardiogram (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).

For an initial injection of Apokyn administered in the neurologist's office, report 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular).

Caution: You should report 90772 only if the neurologist or nurse administers the injection. If the patient self-injects, you cannot charge separately for this service.

Modify it: If you are billing 90772 and the initial injection 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 the injection.

Check for prolonged service: The neurologist might administer more than one Apokyn injection in the office, depending on the patient's response. Depending on the number of injections the physician administers to achieve the optimal dose, you might be able to report prolonged service codes for the visit. If so, submit +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient E/M service]) or +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]), depending on the time your neurologist spends with the patient.

HCPCS includes two codes for Apokyn this year because of the transition to new code J0364 (Injection, apomorphine hydrochloride, 1 mg). Having the code, however, doesn't mean automatic reimbursement: J0364 payment is at carriers- discretion.

Only bill for the Apokyn drug supply if your practice purchased the medication for the patient, says Mary McDermott, MBA, CPC, director of billing quality assurance, Clinical Practice Association, Johns Hopkins University. -If the patient brought his own supply of the drug from a pharmacy, you cannot bill the HCPCS code for the drug,- she adds.

What you-ll do: Before submitting your claim with J0364, check the payer's guidelines to know whether to expect reimbursement and whether the carrier has criteria for you to follow when filing.

Second choice: The second HCPCS code for Apokyn is S0167 (Injection, apomorphine HCl, 1 mg). A note directs you to also see J0364, but some carriers (such as Blue Cross Blue Shield) want S0167 instead.

Your manual may include a check-box notation beside the descriptor for both codes. This represents -quantity alert,- which is a tip-off for you to verify you report the code the correct number of times, depending on the injection amount. Again, only bill for the medication if your physician provides it.

When a patient visits for an initial Apokyn injection, he must remain in your office for a minimum of one hour (or even several hours) following the injection so the physician and staff can assess the patient's response. A nurse must be present the entire time, which might pose a staffing or reimbursement problem for your neurologist.

Here's why: 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.

Solution: If your office cannot afford 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 and remain with the patient during the evaluation phase. You report your neurologist's evaluation and injection services.

Another option: The manufacturer of Apokyn, Vernalis, realized that the extended patient observation time during the initial visit kept some patients -- and physicians -- from using the medication. To help promote the medication's use, the manufacturer now provides observation nurses for the visits through a service called the Apokyn Circle of Care.

Your neurologist can prescribe the care, and the manufacturer will send a nurse -- at no charge to the physician, patient or insurance carrier -- to observe the patient following treatment. For more information, visit www.apokyn.com, and click on the Circle of Care logo. Remember that you won't code for the observation nurse because there's no charge for the service.