Neurology & Pain Management Coding Alert

Question: Our neurologist has agreed to be a specialty resource for a small rural hospital. She recently provided critical care services for an ER patient with acute seizures possibly due to viral encephalitis. But instead of being physically there at the hospital, our neurologist was connected to the hospital via a remote real-time interactive video conference with the physician and ER patient. I know the codes for this E/M service are listed in the CPT Category III section, but they don't have RVUs assigned. How do I know what we'll get paid? Do I need to submit a suggested fee when I report Category III codes?

Ohio Subscriber

Answer: Although the Medicare physician's fee schedule does not assign relative value units (RVUs) to Category III codes, payers may still reimburse you for the codes -- but even if they don't, you must still report the Category III code.

Per the CPT section guidelines for Category III codes,"If a Category III code is available, this code must be reported instead of a Category I unlisted code. This is an activity that is critically important in the evaluation of healthcare delivery and the formation of public and private policy." Check with your individual payers about their Category III code reimbursement policies.

Providers often use the valid codes for other services (which may be Category I codes) as the basis for their fees for these Category III codes since there are no RVU assigned. You should look for a basis code that has similar physician work, malpractice expense, and practice expenses.

For example, you and your neurologist may want to review the Category I critical care E/M codes (99291 and 99292, Critical care, evaluation and management of the critically ill or critically injured patient) for a comparison for these remote critical care services, which are reported with 0188T (Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or critically injured patient; first 30 " 74 minutes) and +0189T (...; each additional 30 minutes [List separately in addition to code for primary service]).

Best bet: Explain this comparison in a cover letter to the payer, detailing what code(s) you based your fee on.