Neurology & Pain Management Coding Alert

Question: The neurologists in our group practice interpret electroencephalograms (EEG) and carotid ultrasound exams at the local hospital. Often, the attending physician orders the ultrasound using a presurgical diagnosis or a "rule-out" diagnosis of carotid stenosis. When the neurologist interprets the ultrasound, the results are normal. The rule-out diagnosis is not acceptable for payment, and a carotid stenosis diagnosis is incorrect. Can we code for these interpretations?

Oklahoma Subscriber

Answer: According to ICD-9 guidelines, report the reason for the encounter when the physician has not determined a definitive diagnosis. 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. You may report these symptoms to justify the necessity for diagnostic tests, such as EEGs 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 physicians to use codes V72.81-V72.84 to provide medical necessity for preoperative clearance exams.

According to Medicare transmittal R1707-B3, dated May 31, "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, you may use the appropriate V code rather than the condition that prompted the concern or the condition that warrants surgery 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 states.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine; and Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.