Neurology & Pain Management Coding Alert

Question: Since Medicare has assigned a physician work value to tissue plasminogen activator for 37195 we are having trouble getting reimbursed for the E/M code. We used modifier 57 on the E/M code, but the payer denied 31795 stating it was included in the E/M service. We also tried modifier 25. Medicare denied that because of an improper place of service: inpatient at hospital facility. How can we report this service so that we get paid for the TPA?

Missouri Subscriber

Answer: Medicare will not pay your neurologist for the tissue plasminogen activator (TPA) infusion in the facility setting.

According to the Medicare Physician Fee Schedule,37195 (Thrombolysis, cerebral, by intravenous infusion) does not have an established relative value unit (RVU) valuation including no established work RVU. Medicare considers the code to be "carrier priced."

There are no Correct Coding Initiative (CCI) edits bundling E/M codes with 37195. Also, 37195 is not bundled into any codes either due to column 1 / column 2 bundling edits or mutually exclusive bundling edits.

The catch: This particular CPT code, however, carries a "5" professional component/technical component status indicator in the Medicare Physician Fee Schedule. There is a stipulation that payers may not reimburse  for these services "when they are provided to hospital inpatients or patients in a hospital outpatient department." You cannot use modifiers 26 (Professional component) and TC (Technical component) with these kinds of codes.

Good news: This doesn't mean, however, that your neurologist doesn't have any billable services in the facility. On the contrary, your physician most likely would be providing an inpatient E/M service (99221, Inpatient hospital care...), probably including critical care services (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). You should be able to report both those, depending upon your neurologist's documentation.

Remember: Not every non-Medicare payer uses all of the Medicare Physician Fee schedule status indicators. Therefore, your private payers may allow for physician reimbursement of 37195 in the facility site of service and/or create their own proprietary bundling edits.

Best bet: You should contact the individual insurance company to see the coverage policy for this particular code.