Neurology & Pain Management Coding Alert

Question: I recently learned that Medicare does not cover 37195 for IV t-PA administration for the treatment of an acute stroke. As the treating neurologist responsible for making the decision and supervising its administration, how should I bill?

South Carolina Subscriber

Answer: Code 37195 (thrombolysis, cerebral, by intravenous infusion) is intended to reflect the administration of the medication and does not involve the physicians role in the planning and supervision of the injection. To be reimbursed for the decision-making and supervision of the administration, you must bill the appropriate E/M service.

The neurologist receives reimbursement for the E/M services that go along with deciding to give the medicine, watching while it is given and following up. Depending on which of the appropriate key components of an E/M service are met there are several choices regarding which to bill:

1. Emergency care services (99281-99288);
2. Initial inpatient care (99221-99223);
3. Subsequent inpatient care (99231-99233);
4. Critical care services (99291-99292);
5. Prolonged care services (99354-99359); and
7. Initial and subsequent care consultation codes (99251-99255, 99261-99263).

For example, if a neurologist wanted to bill the critical care codes for his or her role in the t-PA administration, the key is to bill the total time spent at the patients bedside overseeing/administering hands-on critical care, and to document the nature and time of the critical care delivered. Critical care is defined as the care of the unstable, critically ill or injured patient requiring constant neurologist attendance at the bedside or in work directly related to that patients care. Merely being in the room or at the station in case a problem develops, overseeing intermittent monitoring but otherwise engaged in activity not directly related to that patients critical care, does not qualify.

If the doctors work associated with t-PA involves prolonged physical presence in the ICU/ER area during and after the infusion (on call for blood pressure rise, neurologic change, etc.) but does not involve constant bedside and unit work related to the patients critical care, a prolonged service code is more appropriate.