Neurology & Pain Management Coding Alert

Question: We recently performed a consultation with findings that necessitated a spinal tap on the same day of service. We used the same diagnosis code for the consultation and the spinal tap, but Medicare rejected payment on the consultation while reimbursing for the spinal tap. How should we refile the consultation?

North Carolina Subscriber

Answer: The ICD-9 code used for the consultation should be the reason for the encounter (the condition or symptom for which the primary-care physician originally sought the neurologist's opinion), says Laurie Castillo, MA, CPC, president of Physician Coding & Compliance Consulting, a physician consulting firm in Manassas, Va., and a coding expert on neurology.

"The ICD-9 code for the spinal tap may be a different ICD-9 code or the same," Castillo says. Regardless, when you perform a consultation visit on the same day as a surgical procedure, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consultation code. This informs the insurance company that an E/M service resulted in the decision to perform the procedure.

For example, a patient arrives for a consult because of a sudden, severe headache. A primary diagnosis of 784.0 (Headache) is linked to the consult (e.g., 99243, Office consultation for a new or established patient ). However, to rule out the possibility of meningitis or subarachnoid bleeding, the neurologist opts to perform a spinal tap (e.g., 62270*, Spinal puncture, lumbar, diagnostic) in addition to the E/M service. Because the headache diagnosis prompted the spinal tap, the same ICD-9 code (784.0) may be linked to that procedure. To demonstrate that the E/M service was not simply a routine pretest service, append modifier -25 to the consult code, which is reported in addition to the spinal tap (e.g., 99243-25, 62270).