Neurology & Pain Management Coding Alert

TCD is misunderstood by some payers -- help clear the fog.

Proving medical necessity for transcranial Doppler testing can be tough, but there are some practice-proven strategies that can help you win the day.

Transcranial Doppler testing (TCD) is a noninvasive diagnostic ultrasound evaluation of the intracranial arteries in the head. Neurologists use it to determine if there is an occlusion or stenosis of an artery that can result in cerebrovascular diseases such as stroke and brain hemorrhages, and as a screening study for children with sickle cell anemia. Despite its importance for helping predict future patient well-being, weak or incomplete documentation of a TCD can result in little or no reimbursement. Learn how to avoid any missteps when you code TCD.

Transcranial Doppler studies help diagnose patients who have or may have stenosis, emboli, and hemorrhage by measuring the blood flow through the brain. The codes used for TCD are:

- 93886 -- Transcranial Doppler study of the intracranial arteries; complete study

- 93888 -- ... limited study.

With such straightforward codes, it should be easy for your provider to obtain reimbursement, but not so fast. Reimbursement for this procedure may be challenging if documentation and coding are not clear enough to support medical necessity for the procedure, says Marianne Wink, RHIT, CPC, ACS-EM, with the University of Rochester Medical Center Department of Neurology Coding Office, in Rochester, N.Y.

For example: Your neurologist may order a complete TCD (93886) for a presenting condition such as dizziness (780.4) in a patient who may have additional risk factors for stroke also. Many payers won't pay the claim if you use 780.4 as the primary diagnosis code, Wink says.

The reason:-"Complete documentation of the presenting conditions that highlight medical necessity for the diagnostic procedure must include evidence of a condition that supports the need for the test," Wink explains. This means there must be positive evidence of signs, symptoms, or conditions that can be determined to be causes of potential cerebrovascular disease.-"Coding conditions with generalized symptom codes such as 780.4 do not support the need for a TCD," Wink adds. Dizziness is an indicator of many less acute conditions, such as ear wax or an inner ear infection, and therefore does not indicate medical necessity for a diagnostic study such as a TCD.- -

Many insurance companies don't pay for these tests simply because "they don't understand the TCD's diagnostic capabilities," says Lynn McCormack, CPC, with HCA Physician Services in Las Vegas.

So what steps can you take to get reimbursement for TCD?-"We are successful if providers are accurately documenting the patient's medical condition that creates the medical necessity for the diagnostic test," Wink says. If not, and the coding does not support the procedure, than you cannot appeal a rejection. -

Educate your physician: Consider spending time working on documentation and coding education for your providers to help prevent losses for the practice, Wink recommends. This way, your neurologist's documentation can improve and help pave the way for proper reimbursement.

Remember, CPT 2009 section notes on Non-Invasive Vascular Diagnostic Studies state that vascular studies (including 93886 and 93888) "include patient care required to perform the studies, supervision of the studies and interpretation of study results with copies for patient records of hard copy output with analysis of all data, including bidirectional vascular flow or imaging when provided." Your neurologist's documentation should include notes on these aspects when you submit your claim.

Get help from your physician and AAN: "Thanks to one of our physicians who is a stroke specialist and intensivist, we have a letter explaining what a TCD is and what its diagnostic properties are," McCormack says, adding that in most cases, sending this additional information leads to reimbursement. A similar letter from one of your specialists may have the same effect. McCormack also advocates obtaining and including information from the American Academy of Neurology (AAN). TCD information can be found at www.aan.com.