Neurology & Pain Management Coding Alert

Question: When the physician tests a patient for a concussion, how should I code the service?

New Hampshire Subscriber

Answer: It depends on the type of test the physician uses to check for a concussion.

At times, he might be able to evaluate the concussion during the course of an office evaluation and management (E/M) service, which you’d report with a code from the 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making …) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity …) code set.

Or: The physician might use a computerized test, often a digitized version of the Wisconsin Card Sorting Test, to check for a concussion. In these cases, report the service with 96120 (Neuropsychological testing [e.g., Wisconsin Card Sorting Test], administered by a computer, with qualified health care professional interpretation and report).

Or: The physician could perform a test without a computerization component; this could be the Wisconsin test mentioned earlier, or other tests such as Halstead-Reitan Neuropsychological Battery or the Wechsler Memory Scales. In these cases, select 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 administering tests to the patient and time interpreting these test results and preparing the report) for the encounter.

Or: The physician might perform a non-computerized test during an E/M service. When this occurs, you might not be able to code for the test, as 96118 is bundled into the office E/Ms. If, however, you can demonstrate that the E/M and 96118 were truly separate services, you might be able to report two codes. When coding for the E/M and 96118, you’d need to append modifier 59 (Distinct procedural service) or XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service) to 96118, depending on payer preference.

Best bet: Carefully check the notes, and ask the physician, if you have any doubt as to which concussion test she performed.