Neurology & Pain Management Coding Alert

Because the Physician Fee Schedule assigns no physician work value to 37195 (Thrombolysis, cerebral, by intravenous infusion), neurologists must report an appropriate E/M code to receive reimbursement for t-PA administration. When initial inpatient care (99221-99223) and initial and follow-up consultation (99251-99255, 99261-99263) codes are inappropriate, the neurologist may instead report prolonged services codes +99356 and +99357. Prolonged Services 101 Prolonged services are a unique category of E/M codes that describe face-to-face, physician-to-patient contact "that is beyond the usual service in either the inpatient or outpatient service," according to CPT. If a stroke victim's condition does not warrant constant bedside attention or physician management as described by critical care (99291-99292, see July 2002 Neurology Coding Alert for more information), for instance, but still requires significant time and attention, the prolonged service codes may be an appropriate choice. For neurologists attending to patients in the hospital, applicable codes include:

+99356 Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); first hour (list separately in addition to code for inpatient evaluation and management service)

+99357 each additional 30 minutes (list separately in addition to code for prolonged physician service). Note that prolonged services are add-on codes, which must be reported in addition to other physician services, including E/M services at any level. Note also that +99357 must be reported only in addition to +99356. Got the Time? Prolonged services codes are time-based and may only be appended to other E/M codes that include a reference time (without this time component, there is no way to define a service as "prolonged"), says Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles. Specifically, section 15511.1 of the Medicare Carriers Manual (MCM) dictates that +99356 and +99357 must accompany a claim of 99221-99223 (Hospital inpatient services), 99231-99233 (Subsequent hospital care), 99251-99255 (Initial inpatient consultations), 99261-99263 (Follow-up inpatient consultations), 99301-99303 (Comprehensive nursing facility assessments) or 99311-99313 (Subsequent nursing facility care). Medicare carriers will not reimburse for prolonged services unless they are accompanied by an approved "companion" code, says Cathy Klein, LPN, CPC, medical policy specialist with Health Care Excel Inc. in Indianapolis. Prolonged services cannot be billed with:
hospital observation services observation or inpatient care services (including admissions and discharges) critical care services emergency department services (unless the physician is providing an outpatient consultation that goes beyond the typical time spent with a patient). When you report the first hour of prolonged services, the reference time for the primary E/M service must be exceeded by a minimum of 30 minutes. For neurologists providing [...]