Neurology & Pain Management Coding Alert

Question: Mrs. Jones came to our office for cognitive tests (96118), and our physician prepared the reports later that day. She could not come to the office for a follow-up visit, so the physician reviewed the results with her over the phone two weeks later. What date of service should we report?

Minnesota Subscriber

Answer: Practices handle this situation different ways, but your most conservative approach is billing 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) for the initial date of service.

Then report an E/M code for the phone visit (on that date of service), based on the amount of time your physician spent on the call. Your most likely option is 99371 (Telephone call by a physician to patient or for consultation or medical management or for coordinating

medical management with other healthcare professionals [e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists]; simple or brief [e.g., to report on tests and/or laboratory results, to clarify or alter previous instructions, to integrate new information from other health professionals into the medical treatment plan, or to adjust therapy]).

Caution: Some payers might not reimburse for services your physician does not provide face-to-face, such as the telephone call. Be aware of this as you work with your payers and file the claim.