Neurology & Pain Management Coding Alert

Neurologists often have problems getting reimbursed from Medicare and other third-party payers for performing various tests on patients who may have had a stroke. Problems can develop because the neurologist did not chose the appropriate ICD-9 or CPT codes. If he or she does not provide documentation for the medical necessity of the tests, problems may arise because carriers do not understand the need for more than one test, or they may not be covered by the insurance carrier. Avoid denials by properly coding and documenting the reasons for the tests in the patients file.

Coding Signs and Symptoms

If the diagnosis is not known before the test is performed, the claim should be coded based on the signs and symptoms noted by the neurologist when the test is ordered. According to Karen Duane, CPC, coding specialist for the Phoenix-based Barrow Neurological Institute, one of the largest full-service neuroscience centers in the southwestern United States with 20 neurologists, if the test is being performed to see if the patient has had a stroke, then the common signs and symptoms include: paralysis (344.9), hemiplegias (342.91), occlusion of certain arteries (434.9x or 433.1x), stenosis (447.1), aneurysyms (442.9), speech problems (784.5), injuries to blood vessels (904.9), cerebral artheriosclerosis (437.0), transient cerebral ischemia (435.9), and vision loss (369.9). Duane also suggests that the coder check with his or her local Medicare carrier and third-party payers to obtain a list of which diagnosis codes are approved for the tests that the neurologist wants to perform.

Note: Make sure the ICD-9 code accurately represents the diagnosis. Never choose an ICD-9 code just because you know it will get the procedure code reimbursed.

Diagnostic Tests for Stroke

Steven W. Dibert, MD, a neurologist at the Neuroscience and Spine Center in Gastonia, N.C., and member of the board of directors of the American Society of Neuroimaging as well as the board of the American Academy of Neurology/Neuroimaging Section, offers the following example of diagnostic tests for strokes: A patient may have stenosis of an artery in their head, and the neurologist orders a magnetic resonance angiography (MRA) 70541, magnetic resonance angiography, head and/or neck, with or without contrast material[s]) or a magnetic resonance imaging (MRI) to look at the blood vessels in the head (70551, magnetic resonance [e.g., proton] imaging, brain [including brain stem]; without contrast material) or 70553, magnetic resonance [e.g., proton] imaging, brain [including brain stem]; without contrast material, followed by contrast material[s] and further sequences) to see where the stroke took place and whether it was embolic (a piece of material that came up an artery and caused the stroke) or thrombotic (the artery closed off within the brain itself).

Other tests that can be performed to diagnose stroke include the cerebrovascular arterial studies (93875, noninvasive physiologic studies of extracranial arteries, complete bilateral study [e.g., periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis], 93880, duplex scan of extracranial arteries; complete bilateral study; and 93882, duplex scan of extracranial arteries; unilateral or limited study). These tests are used to examine the carotid artery. Transcranial Doppler tests (93886, transcranial Doppler study of the intracranial arteries; complete study) and 93888 (transcranial Doppler study of the intracranial arteries; limited study) also are used to examine the intracranial arteries. Duane reports that if these tests are done in a hospital, the coder will need to bill them with the modifier -26 (professional component) to show that the neurologist only interpreted the results of the tests.

Medical Necessity for Testing

Derk W. Krieger, MD, a fellow of the American Academy of Neurology and the American Heart Association and member of the department of neurology section of intensive stroke and neurologic intensive care at the Cleveland Clinic Foundation in Cleveland, reports that some insurance carriers will not cover both an MRI and an ultrasound on the same patient if they are done on the same arteries. He recommends contacting the insurance carriers ahead of time to learn if they have such restrictions.

If a neurologist needs to perform additional testing, the reasons should be documented in the patients file in detail to prevent denials, Krieger advises. For example, a patient may have had a stroke and is sent for a CAT scan (70450, computerized axial tomography, head or brain; without contrast material) at the emergency room. The results come back, and the neurologist feels that it may have been a brain stem stroke.

The patient would then be sent for an MRI because a brain stem stroke cannot be seen properly on a CAT scan. The neurologist would document in the patients file the reasons for believing the stroke might have occurred in the brain stem to provide the medical necessity for performing the additional testing. The neurologist also will need to provide copies of the results of the tests to the insurance carrier to further document the medical necessity.

Dibert also reports that performing multiple testing can have an effect on the treatment given to the patient. For example, if a stroke was due to bleeding, then blood thinning medications would not be given to the patient because that only would make the bleeding increase. But if the stroke was caused by lack of blood flow, then it would be safe to give that patient blood thinning medication. This information can be found out only through multiple tests. Also, a neurologist sometimes will want to confirm the diagnosis with additional testing to obtain as much information as possible about the patients condition.

Verify Tests Are Reimbursable

Dibert states that some tests that are used to diagnose strokes are not covered by certain payers, and this needs to be researched before the neurologist performs the test to prevent problems with reimbursement down the road. For example, in North Carolina, up until last year, Medicare would not pay for a neurologist to perform an MRA unless stroke already was diagnosed. In other words, an MRA could not be used as a diagnostic tool.

If carriers deny payment because more than one test was performed, full documentation should be sent in with the appeal. Dibert suggests sending a copy of reports read by the neurologist at the time of billing if the carrier has a history of issuing such denials.