Neurology & Pain Management Coding Alert

Neurologists who report t-PA administration to stroke victims using only 37195 (Thrombolysis, cerebral, by intravenous infusion) are forfeiting deserved reimbursement. That's because 37195, although appropriate to describe intravenous thrombolysis infusion, has been assigned no physician work value, according to the latest Physician Fee Schedule. Reimbursement for the service is included in any accompanying E/M service rendered during the same session. The type of E/M service provided can vary from patient to patient, however, thereby complicating code choices and documentation. So Many Choices Depending on the patient and circumstances (as well as the accompanying documentation), any of four E/M service code categories can be assigned to accompany 37195:

Critical care services (99291-99292) Prolonged care services (99356-99357, 99358-99359) Initial inpatient care (99221-99223) Initial and follow-up consultation codes (99251-99255, 99261-99263). Of the four categories, critical care requires the highest level of physician involvement, but it also provides the highest reimbursement. Documentation requirements for critical care are exacting, and only a minority of patients qualify for critical care services.

According to CPT, "Critical care is the direct delivery by a physician of medical care for a critically ill or critically injured patient." CPT further specifies that a critical illness or injury acutely impairs one or more vital organ systems such that the patient's survival is jeopardized. The care of such patients involves decision making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration. Stroke patients requiring t-PA meet the criteria for critical care if there is "a high probability of sudden, clinically significant or life-threatening deterioration in the patient's condition that requires the highest level of physician preparedness to intervene urgently," explains Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting in Manassas, Va., citing CMS guidelines. She notes that intravenous t-PA administration in stroke victims has a 12 percent risk of fatal cranial hemorrhage, and CMS instructions to Medicare providers specifically indicate, "Critical care services require direct personal management by the physician. They are life- and organ-supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis likely would result in sudden, clinically significant or life-threatening deterioration in the patient's condition."

Although critical care is generally provided in a critical or intensive care unit, it need not be. By the same token, however, not all patients in the critical or intensive care unit warrant use of critical care services: As long as the requirements of critical care are met, 99291-99292 may be [...]