Neurology & Pain Management Coding Alert

Epley maneuver and other new codes offer more places to get reimbursement.

The time to implement the annual CPT updates is almost here already. Remember how reporting canalith repositioning used to be a cross-your-fingers procedure? Not anymore. Gear up for 2009 with a crash course in changes most likely to affectyour neurologist's practice.

Two of the biggest additions to neuro-specific codes include canalith repositioning (aka the Epley maneuver) and actigraphy, a sleep testing code. Here's what you need to know about Epley.

- 95992 -- Canalith repositioning procedure(s) (e.g., Epley maneuver, Semont maneuver), per day

In 2008 and before, physicians often included Epley work in an E/M code reported that day, or reported Epley as 95999 (Unlisted neurological or neuromuscular diagnostic procedure) or 92700 (Unlisted otorhinolaryngological service or procedure),says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, from MJH Consulting in Denver. These codes were recommended by some payers as the best for the Epley, even though they are unlisted procedure codes. Relative value units

(RVUs) for 95992 are 1.13 for non-facility, and 1.02 for facility in 2009. But the new CPT code for the Canalith procedure will carry a "B" or bundled status indicator for Medicare, Hammer adds.-"Even though there are established RVUs for the new code, Medicare won't be allowing separate payment for the service."-According to CMS, physicians-should continue to report this service as included in their E/M services. "It will be up in the air for commercial payers as to how or if they will separately process this new CPT code for payment," Hammer says.

Heads up: There has been a valid HCPCS code for canalith repositioning for some years, S9092 (Canalith repositioning, per visit), but Medicare does not recognize S codes. While most Blue Cross/Blue Shield and some additional commercial payers recognize S codes, such HCPCS codes have no established relative value units.

-95803 -- Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)

What it is: Actigraphy uses a motion detection sensor that, like a wrist watch, is typically worn on the nondominant wrist, says Sam Fleishman, MD, medical director of the Sleep Center in Cape Fear Valley, N.C. "By monitoring movements one can get a measure of an individual's rest and activity periods and thus get a sense of one's sleep/wake patterns over time," Fleishman says. Patients wear the actigraph for up to two weeks. The information is downloaded and analyzed with a statistical and graphic printout, and correlated with the patient's subjective report with a sleep diary.

What it's worth to you: According to CMS, carriers will price this code, establishing RVUs and payment amounts for these services on an individual case basis following review of documentation, such as the diagnostic study report.

Prepare to update your coding with more than 95992 and 95803:

-64455 -- Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (e.g., Morton's neuroma)

This new code is important due to its specificity, says Hammer. It is more exact than using 64450 (Injection, anesthetic agent; other peripheral nerve or branch). "Plus, some Medicare carriers, such as Noridian,-had issues with providers reporting 64450 for an injection of Morton's neuroma," and wanted you to use 64999 (Unlisted procedure, nervous system), Hammer adds. "The AMA directs providers to report 64455 one time only, regardless of the number of injections performed during a session," she says.

-64632 -- Destruction by neurolytic agent; plantar common digital nerve

Like 64455, this new code adds more specificity than using the previously available option -- in this case, 64640 (. . . other peripheral nerve or branch).

-J1953-- Injection, levetiracetam, 10 mg

For the second time in as many years, levetiracetam -- an anti-seizure medication -- has undergone a change in HCPCS. Beginning Jan. 1, 2008, you coded the drug C9238 (Injection, levetiracetam, 10 mg), because it was a newly added drug code at the time. Remember that HCPCS states C codes are appropriate for facility (technical) services. The code has been changed to a J code ("Drugs administered other than oral") for 2009.

-96360--"96379 -- Hydration, Injections, and Infusions

The infusions and injection code set moved to a new code range in the Medicine section. Codes 90760-90799 moved to 96360-96379. This appears to be more of an organizational renumbering move to assist coders in more convenient comparison to the chemotherapy infusion/ injection code range, Hammer says. The section guidelines likewise have been relocated and revised to encompass the entire set of injection/infusion code range of 96401-96542.

-99354 -- Prolonged physician service in the office or other outpatient setting requiring direct (face-to- face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)

An example related to an acute asthmatic patient was deleted from this code description, so fortunately you don't have to learn a huge change. CPT made the decision "probably more for clarification and perhaps to eliminate any payer confusion over usage," Hammer says.

-99356 -- Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)

This code added "unit/floor time" and deleted verbiage regarding direct (face-to-face) patient contact. CPT also deleted an example in the code description. "This is more of a correction, as historically using time as the basis for a level of an inpatient E/M service in the inpatient setting was not a face-to-face requirement but rather a unit/floor time requirement, so it appears that they are revising the prolonged service code to match the requirement for those applicable E/M codes," Hammer clarifies.