Neurology & Pain Management Coding Alert

Take care not to report codes included in services you've already claimed

Medicare payers complain that they consistently see the same coding errors time after time. Here's your chance to learn from you own (and everyone else's) mistakes: A quick review of these three coding basics can go a long way toward protecting your practice's reimbursement.

Learn more: This feature is the second in a two-part series on the top-10 reasons for Medicare claims rejections. For additional information, refer to "Avoid the Most Common Reason CMS Denies Your Claim," Neurology Coding Alert, September 2005.

1. Prevent Unbundling

Anytime you report more than one CPT code on a claim form, you must consider that one or more of the services you are reporting could be an included component of another, more extensive procedure that you've also claimed.

Reporting an included service separately is called "unbundling," and it's one of the most common problems with Medicare claims, according to CMS.

Example: The neurologist conducts a nerve conduction study without F-waves on the ulnar nerve (95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study). Realizing he requires more data, he performs NCS on the same nerve a second time, but with F-waves (95903, ... motor, with F-wave study). On seeing the neurologist's documentation of nerve conduction with and without F-wave, the coder reports separate units of 95900 and 95903.

Here's the mistake: The National Correct Coding Initiative bundles 95900 to 95903 for tests on the same nerve. Therefore, in this case the coder should have reported only the more extensive procedure (95903).

Solution: Always keep an updated version of the NCCI nearby and refer to it regularly.

Free resource: You can access the NCCI edits without cost at the CMS Web site http://cms.hhs.gov/physicians/cciedits/default.asp, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. The same Web page also includes links to documents that explain the edits, including the NCCI Policy Manual for Part B Medicare Carriers, the Medicare Carriers Manual, and an NCCI Question-and-Answer page.

CPT parenthetical notes matter, too: For instance, pain pump codes 64416, 64446, 64448 and 64449 include daily drug management as reported by 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration), as outlined elsewhere in this issue ("Continuous Infusion Codes Are the Way to Go for Your Pain Pump Claims,"). If you fail to read the parenthetical note in CPT following the pain pump code descriptors, you could easily - but incorrectly - report 01996 in addition to 64416, 64446, 64448 or 64449.

2. Avoid Modifier Mishaps

Learning proper application of modifiers is crucial to successful coding. In particular, Medicare sees the greatest number of problems with modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 59 (Distinct procedural service).

Same-day E/M, other service, calls for 25: CMS policy dictates that all procedures, from simple injections to common diagnostic tests, include an inherent E/M component. Therefore, any E/M service you report separately must be above and beyond the E/M service the physician normally provides as a part of the procedure billed, says April Borgstedt, CPC, president of Working for You Consulting in Broken Arrow, Okla.

Example: A new patient with a possible diagnosis of carpal tunnel syndrome (354.0) arrives for a consult with the neurologist. The neurologist provides a full E/M service, spending about 40 minutes taking the patient's history, performing an exam and, finally, deciding to conduct several electrodiagnostic tests, including electromyogram and NCS, which she administers during the same visit.

To report the visit, you claim the appropriate test codes (for example, 95860, Needle electromyography; one extremity with or without related paraspinal areas and 95900) along with 99243 (Office consultation for a new or established patient ...) for the E/M service. You should append modifier 25 to 99243 to show the payer that the E/M service was significant and separate from the "inherent" E/M component of 95860/95900.

Apply 59 With Caution

CPT specifies that you should use modifier 59 to indicate a procedure or service that is "distinct or independent from other services performed on the same day" and, further, that the two services/procedures are "not normally reported together, but are appropriate under the circumstances."

Bottom line: Only append modifier 59 to a claim if you are certain of the distinct nature of the procedures you are reporting, and never simply to override NCCI bundles to get paid, says William J. Conner, MD, founder of Conner Health Clinic, a multispecialty practice in Charlotte, N.C.

Example: Let's return to our earlier example of the neurologist providing NCS with and without F-wave. Except, in this case, the neurologist conducts the NCS without F-wave on the ulnar nerve and NCS with F-wave on the radial nerve. Because the neurologist provided the services on two separate sites, you are justified in reporting both 95900 and 95903. You must, however, append modifier 59 to the lesser service (95900) to override the NCCI edit that bundles 95900 to 95903.

3. Rethink Your E/M Strategy

You should avoid the practice of assigning a "standard" E/M level (for instance, 99213 for an established patient) for all E/M services.
 
CMS will deny your claims if statistical evidence suggests your practice is consistently over or under-assigning E/M levels.

Solution: "When assigning E/M levels, there are few shortcuts," Jandroep says. "You've got to look at the physician's documentation and determine the extent of the history, exam and medical decision-making [MDM]. If you just say, 'If the physician meets with the patient for a new complaint, it's a 99213,' you're going to have problems."

Tip: For new patient office visits (99201-99205) and consults 99241-99255, you must base the E/M level on all three key components (history, exam and MDM). For established patient visits (99211-99215) and consults 99261-99263, you need to match only two of the three key components to choose an E/M level.

Example: The neurologist meets with a new patient with new, recent symptoms. She conducts and documents a detailed history and an expanded exam, with low-complexity MDM. The neurologist records spending 30 minutes with the patient.

The coder, seeing the "30 minute" reference and noting that this is a first-time visit, automatically assigns 99203 (Office our other outpatient visit for the evaluation and management of a new patient ...). This visit does not meet the requirements of 99203, however, because the neurologist only documented an expanded, rather than a detailed, examination.

Remember: You can report E/M services by time only, but only if more than 50 percent of the visit involves counseling or coordination of care.