Neurology & Pain Management Coding Alert

You're fairly clear on prolonged services codes, but you'd like a little practice, right? Try coding the following case studies and then review the responses offered by our experts to test your coding skills.
 
Case #1: The neurologist sees an elderly established patient who has been in an automobile accident and has been complaining of lower-back pain. The neurologist provides an E/M service that qualifies as a level-three outpatient visit (99213). The patient's ride is late, and he begins to show signs of fatigue and confusion while complaining of increasing pain. Over the next two hours, the physician spends about 40 additional minutes monitoring the patient's status.
 
Coding #1: In this case, because the physician provided services beyond those typically included in a level-three established patient office visit (requiring 42 minutes longer than the 15-minute reference time for 99213), you may report 99213, 99354.

Case #2: The neurologist provides a level-three hospital admission (99223) for a 55-year-old male stroke patient. The patient does not require attention at the level of critical care (99291-99292), but he does require significant care and attention (including t-PA administration: 37195, Thrombolysis, cerebral, by intravenous infusion). The visit lasts a total of 110 minutes.
 
Coding #2: In this case, you will report the hospital admission (99223), the t-PA administration (37195), and one unit of +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]). The reference time for 99223 is 70 minutes. Because the total time the  neurologist spends with the patient exceeds this time by at least 30 minutes (110 minutes - 70 minutes = 40 minutes), you may report prolonged services.

Case #3: A patient arrives for a consult concerning possible treatment with facet joint injections for back pain. The physician examines the patient and spends an additional 25 minutes discussing the merits of various treatments. Based on history, exam and MDM, the service qualifies as a level-two consult (99242). The total visit lasts 45 minutes.
 
Coding #3: In this example, the neurologist's face-to-face time with the patient does not meet the threshold for prolonged services. CPT lists a reference time of 30 minutes for 99242, leaving only an additional 15 minutes unaccounted for - not enough to report prolonged services.
 
But because counseling makes up more than 50 percent of this visit (25 of 45 minutes), you can choose an E/M level based on time alone. In this case, you should report code 99243 (Office consultation for a new or established patient ...), which has a reference time of 40 minutes).