Neurology & Pain Management Coding Alert

Question: May I code based on time if my neurologist conducts a mini-mental state exam (MMSE)?

Virginia Subscriber

Answer: The parenthetical note in the 2008 CPT manual under Central Nervous System Assessments/Tests indicates you should look to the E/M codes for a MMSE performed by a physician. The MMSE is a screening tool used to assess cognitive function. It typically takes approximately 10 minutes to complete, and neurologists often use the test by to evaluate patients with possible Alzheimer's disease or another related dementia.

Time-based coding: For most E/M services, if your neurologist spends more than 50 percent of the total visit time in counseling and coordination of care with a patient and/or family members, you may use time as the determining factor. CPT defines counseling as a discussion with a patient and/or family concerning one or more of the following areas:

- diagnostic results, impressions and/or recommended diagnostic studies

- prognosis

- risks and benefits of management (treatment) options

- instructions for management (treatment) and/or follow-up

- importance of compliance with chosen management (treatment) options

- risk factor reduction

- patient and family education.

For example: If a neurologist discusses the MMSE diagnostic findings, prognosis and/or management options with an established patient and/or with the patient's family, for 30 minutes of a 55-minute visit, you may report the visit with 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family) based on time spent. Maintaining careful documentation outlining total visit time, the time spent counseling and/or coordinating care and sufficient detail as to the extent of the counseling is important to support your code choice.

Prolonged services: Before you consider using add-on code +99354 (Prolonged physician service in the office or other outpatient setting -) or +99356 (Prolonged physician service in the inpatient setting) for prolonged services involving direct (face-to-face) patient contact , remember these codes require the total duration of the prolonged services to be at least 30 minutes beyond the standard time established for the E/M service code.

The CPT guidelines for prolonged services point out that you shouldn't report separately a prolonged service of less than 30 minutes total duration on a given date because the work involved is included in the total work of the E/M codes. In most cases, performance and documentation of the MMSE during a patient E/M visit would not support reporting a prolonged service add-on code.