Neurology & Pain Management Coding Alert

Question: Medicare denied an office visit coded as 99213, plus 99354-21 because of how much time our neurologist spent with the patient. How should I have reported this visit?

Maryland Subscriber

Answer: Medicare might have denied the claim because of modifier 21 (Prolonged evaluation and management services). Some carriers (such as Indiana Medicare) pay for prolonged E/M services without modifier 21, so double-check your carrier's policy before resubmitting the claim.

The codes you reported should be correct, assuming your neurologist's documentation supports them. Submit 99213 (Office or other outpatient visit for the evaluation and management of an established patient ....) with add-on code +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient E/M service]).

Another option: If your neurologist meets the service and time criteria, your carrier might want you to report 99215 instead of 99354. Check your local guidelines to verify which code they prefer.