Neurology & Pain Management Coding Alert

Watch these 2 areas to keep your claims legit

If correctly reporting CPT 96118 and CPT 96119 tests your coding savvy, know that help is on the way. Stay up-to-speed on payer policies and Correct Coding Initiative edits to make the grade every time.

Start by Catching Descriptor Differences

CPT Includes two codes for face-to-face neuropsychological testing:

- 96118 -- Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report

- 96119 -- Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified healthcare professional interpretation and report, administered by technician, per hour of technician time, face-to-face.

Before reporting either code, look closely at what makes them different. Code 96118 is for tests a psychologist or physician administers; the psychologist or physician also interprets the test results and prepares the report. Code 96119 represents tests that a technician administers; another "qualified healthcare professional" completes the interpretation and report.

Here's How to Handle Multiple Tests

In the past, you could report 96118 and 96119 for the same patient on the same day if your providers fulfilled the requirements. Now, however, payers are at odds on how to handle claims when both codes apply to the patient on the same day.

Medicare stance: Medicare's Correct Coding Initiative (CCI) edits consider 96119 to be mutually exclusive to 96118 -- which means you shouldn't normally report both codes during the same visit. You can bypass the edit, however, with a modifier if the tests are separate and distinct from one another.

CMS viewpoint: The CMS Claims Processing Manual added an explanation in 2006 to further explain the matter. The explanation states in part that "CPT neuropsychological test code 96118 should not be paid when billed for the same tests or services performed under neuropsychological test codes 96119 or 96120. However, CPT codes 96101 and 96118 can be paid separately on the rare occasion when billed on the same date of service for different and separate tests from 96102, 96103, 96119 and 96120."

OIG Is Watching Your Modifier Use

Before you jump on the modifier bandwagon to split your 96118 and 96119 services, be sure it's the correct thing to do. Keep these points in mind as you consider the claim:

- Check for the appropriate modifier. You-ll probably report modifier 59 (Distinct procedural service) to unbundle the procedure codes, but that's not an automatic choice. Sometimes other modifiers come into play when you-re bypassing CCI edits, so verify that you-re reporting the modifier that supports your reason for bypassing the edit.

- Review the documentation. Review all the supporting documentation to determine if you-re correct in bypassing the bundling edit. Were two separate and distinct neuropsychological tests performed? Was one performed by a physician or psychologist and the other by a technician?

- Know that OIG is watching. For several years, the Office of Inspector General's (OIG) Work Plan included checking the incorrect use of modifiers to bypass CCI edits. In 2006, the OIG sent a note reminding Medicare carriers to pay attention to incorrect use of modifiers to bypass the edits, so many carriers watch these claims more closely than before.

Why they do it: One of the OIG studies found that 40 percent of code pairs billed in 2003 did not meet program requirements -- which led to an estimated $59 million in improper payments. With that kind of reimbursement on the line, OIG is likely to continue its interest in claims for unbundled edits.