Neurology & Pain Management Coding Alert

E/M documentation guidelines do not take into account the special circumstances associated with performing neurology exams on children. In 1997, CMS unveiled new guidelines that allowed for an extensive, single-system evaluation in place of the multisystem examination required by the previous (1995) guidelines. Although advantageous in most circumstances, the 1997 guidelines contained requirements (e.g., memory and language tests) that could not be met for younger patients. In spite of this, however, pediatric neurologists may still report their services at an appropriate level by substituting the listed elements of the single-system evaluation for other, relevant exam criteria.
 
1997 Guidelines Allow for Substitution

Neurological exams are reported using the appropriate new or established patient E/M service code (99201-99205 or 99211-99215). But among the elements, or "bullet points," listed in the 1997 E/M documentation guidelines for a neurological examination are several items that cannot reasonably be performed on younger children and infants, says Bruce H. Cohen, MD, chief of pediatric neurology at Cleveland Clinic Foundation in Cleveland, including examination of gait and station, orientation to time, place and person, fund of knowledge (e.g., awareness of current and past events) and language and naming skills. Because of this, the neurologist who performs such an examination on an infant or young child will find it difficult to document the required number of elements to report anything beyond a low-level (i.e., problem-focused or extended problem-focused) exam and, thus, be unable to report an E/M service code that accurately reflects the work expended.
 
Note: The 1997 (and 1995) Documentation Guidelines for E/M services, including the requirements for a single-system neurological exam, may be viewed as a .pdf or WordPerfect file by visiting the CMS Web site at: www.hcfa. gov/medlearn/emdoc.htm.
 
Fortunately, CMS recognizes this shortcoming and allows physicians to substitute specifically bulleted items for other, case-appropriate exam criteria. In describing the documentation of E/M services, the 1997 guidelines explain that the requirements "reflect the needs of the typical adult population. For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area."
 
The guidelines also specifically note that "As an example, newborn records may include under history of the present illness (HPI) the details of mother's pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, the content of a pediatric examination will vary with the age and development of the child. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate."
 
Therefore, when you provide a pediatric neurology exam, substituting tests such as a startle reflex and other neonatal reflexes or measurement of cranial circumference and shape for language testing or examination of gait is legitimate. "The idea is to try to match, point-for-point, the elements included as part of the exam.You want to show that the same amount of physician work is involved. For each item that you cannot perform due to the patient's age or cognitive development, substitute a relevant replacement item," Cohen says. In this way, the neurologist can prove that a detailed or comprehensive examination has occurred even though the specific bullet points included in the documentation requirements have not been covered.
 
"Do not devalue the cognitive exam, even in newborns," Cohen advises. "They can make eye contact, generate a reflexive smile, mimic facial movements, have language function like cooing and respond to voice by turning the head. At the very least, the neurologist can say, 'The child cooed responsively, indicative of the maximum degree of language function that can be expected in a child this age.' "
 
When substituting bullet points, be sure to address all the required elements when claiming a detailed or comprehensive examination if only to explain that no results could be gained. For example, documentation might note, "Unable to perform language testing due to patient's age." This provides further proof that the physician took the time to consider all elements of the exam, thereby providing as thorough an evaluation as possible.
 
Note: The 1997 guidelines list a total of 25 bulleted points as part of a single-system neurological exam. A problem-focused exam must cover one to five elements; an expanded problem-focused exam covers at least six elements; a detailed exam covers at least 12 elements; a comprehensive exam must cover all 25 elements.
 
Documenting History and MDM

Just as the exam portion of an E/M service for pediatric patients may require special consideration, the history and medical decision-making (MDM) portions of the service may differ from those of adult patients. For example, developmental and family history (including the parents' status) take a great deal of time and may as noted in the portion of the guidelines quoted above act as the equivalent of a history of present illness and social history, Cohen says. Once again, the task is to substitute relevant information for the required portion of the E/M service that cannot be met for younger patients, thereby allowing the physician to gain legitimate reimbursement.    

For children with pre- or coexisting medical conditions, a necessary review of records and consideration of complicating factors often contributes to the level of MDM much as they would for an adult. But, unlike an adult, an infant or toddler cannot describe symptoms or otherwise provide verbal instruction or information to the physician. This also contributes to the level of MDM. Documentation should note such extenuating circumstances, thereby providing further support for the selected E/M service level.

CPT and CMS guidelines allow physicians to consider time the key or controlling factor to qualify for a given level of E/M service if the visit consists predominantly of counseling or coordination of care, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, consultant and CPC trainer for A+ Medical Management and Education in Egg Harbor City, N.J. This method of choosing an E/M level can be especially useful for reporting patient encounters that do not based on the elements of exam, history and MDM qualify as an upper-level (e.g., 99204-99205 or 99214-99215) service, but that still require a great deal of physician time and/or effort.
 
Young children can be especially uncooperative or unresponsive during an examination. Procedures that are easily performed on an adult, such as cranial nerve testing, can be frustrating and time-consuming to carry out on a restless 2-year-old, and a simple neurological exam can stretch to 90 minutes. In addition, the neurologist may have to spend extra time explaining tests being performed and their results, possible diagnoses, and treatment options to anxious parents.
 
When using time as a determining factor, physicians should consult the "reference" times assigned to each level of E/M service code in the CPT manual, Jandroep says. The time spent face-to-face with the patient must meet or exceed the reference time for the selected code, and a minimum of 50 percent of that time must be spent on counseling and coordination and care. "Counseling and coordination of care" could entail coaxing a child to sit still long enough to perform the required elements of the exam. If there is any chance that time will be the major factor in determining the level of E/M, the physician should carefully document start and stop times for the visit, as well as the content of the visit that required the time-intensive service.
 
For example, the physician conducts a neurological exam on a new patient a "fussy," tantrum-prone 28-month-old child. Nearly 50 minutes of the 75-minute visit were spent gaining the child's confidence (so that the exam could proceed) and discussing results with the parents. Assuming that the visit is properly documented, the physician may report 99205 (Office or other outpatient visit for the evaluation and management of a new patient ), which has a reference time of 60 minutes. In this case, the reference time for 99205 is met, and at least 50 percent of the visit (50 of 75 minutes) is spent on counseling and coordination of care. Likewise, if the visit had lasted 45 minutes, of which at least 23 minutes were spent on counseling and coordination of care, 99204 would be appropriate.