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Neurology & Pain Management Coding Alert

Reader Question:

E/M Codes Provide Payment for t-PA

Published on Thu May 01, 2003

Question: We have been using a surgery code (37195) for the injection of t-PA for stroke. Is this correct?

Michigan Subscriber

Answer: Code 37195 (Thrombolysis, cerebral, by intravenous infusion), although appropriate to describe intravenous thrombolysis infusion, offers no payment because the Physician Fee Schedule has assigned it no relative value units (RVUs). Rather, payers reimburse for t-PA administration as part of any E/M service rendered. Specifically, the American Academy of Neurologists comments, "This code [37195] is intended to reflect the administration of the medication and does not involve an E/M service. Physicians will not generally use this code, therefore. If the appropriate key components of an E/M service are met, a level of E/M may be reported in addition to code 37195."

Depending on the patient and circumstances, you may assign any of several E/M service code categories to accompany 37195. These may include:

  • Critical care services (99291-99292)
  • Prolonged care (99356-99357, 99358-99359)
  • Initial inpatient care (99221-99223)
  • Initial and follow-up consultations (99251-99255, 99261-99263).

    Other categories of E/M that may apply include emergency care services and subsequent inpatient care. In each case, be sure to document properly, showing medical justification for the service(s) rendered.

    Documentation requirements for critical care, in particular, are strict, and only a minority of patients will qualify for these services. Per CPT rules, stroke patients requiring t-PA meet the criteria for critical care if there is "a high probability of sudden, clinically significant or life-threatening deterioration in the patient's condition that requires the highest level of physician preparedness to intervene urgently." At minimum, the physician must document 30 minutes of critical care to code 99291-99292.

    Note: For complete information on t-PA, see Neurology Coding Alert, June, July and August 2002.

     

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