Neurology & Pain Management Coding Alert

Question: The neurologists in our group practice interpret EEG and carotid ultrasound exams at the local hospital, where they have privileges. Often, the attending physician orders the ultrasound using a presurgical diagnosis or a "rule-out" diagnosis of carotid stenosis. When the neurologist reads the ultrasound, the results are normal. The rule-out diagnosis is not acceptable for payment, and a carotid stenosis diagnosis is incorrect. Which diagnosis code can we use to get paid?

Oklahoma Subscriber  
Answer: Report the reason for the encounter when a definitive diagnosis has not been determined. Therefore, report any presenting signs and/or symptoms that prompted the tests.
 
For example, a patient may present with momentary loss of vision, weakness or numbness on one side of the body, and slurred speech, causing the neurologist to suspect carotid stenosis. These symptoms may be reported to justify the necessity for diagnostic tests, such as electroencephalograms (EEG) and carotid ultrasound examinations.
 
Be aware, however, that CMS revised section 15047 of the Medicare Carriers Manual (MCM) to ensure that local Medicare carriers allow the use of codes V72.81-V72.84 to provide medical necessity for preoperative clearance exams.
 
Medicare transmittal R1707-B3, dated May 31, specifies, "Carriers should delete any processing edits that deny claims [for] or identify for manual review ICD codes V72.81 through V72.84." However, "claims containing these codes are subject to medical-necessity determinations as described in MCM section 15047H."
 
According to the new language in section 15047C, Medicare will pay for all medically necessary preoperative clearances, such as those that involve "evaluating a patient's risk of perioperative complications and to optimize perioperative care."
 
This means, for example, that when a surgeon sends a patient to a primary care physician (PCP) or medical specialist for preoperative clearance, the appropriate V code -- rather than the condition that prompted the concern or the condition that warrants surgery -- may be used to justify the examination.
 
According to the revised language in section 15047G, "All claims for preoperative medical examination and preoperative diagnostic tests (i.e., preoperative medical evaluations) must be accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81-V72.84). Additionally, the appropriate ICD-9 code for the condition(s) that prompted surgery must also be documented on the claim. Other diagnoses and conditions affecting the patient [presumably, the condition that concerned the surgeon enough to send the patient to the PCP or specialist for a preoperative clearance] should also be documented on the claim, if appropriate."
 
The transmittal specifies, however, "The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81-V72.84)."
 
Medical necessity for preoperative clearance remains at the discretion of the local Medicare carrier, CMS says.
 
Note: Be sure to attach modifier -26 (professional component) [...]