Neurology & Pain Management Coding Alert

You might be an ace at coding complex degenerative conditions such as multiple sclerosis (340) or Parkinson's disease (332.0, Paralysis agitans), but don't let non-neurological conditions such as urinary tract infection (UTI) or sepsis trip you up. Knowing the subtleties of how these conditions sometimes relate to neurological conditions will help keep your next nonstandard claim clean.

At first glance, urinary or sepsis problems might seem unrelated to neurological conditions, but a UTI can lead to neurological problems in elderly patients.

"UTI means there are microorganisms in the urine (bacteria, fungus, etc.)," says Eugene C. Lai, MD, PhD, professor in the department of neurology at Baylor College of Medicine in Houston. "It may be asymptomatic, but in the elderly population, it -- and the antibiotics used to treat it -- can cause encephalopathy with altered mental status."

Even more serious: When blood cultures grow out of infectious agents and spread throughout the body via the bloodstream, the physician might diagnose septicemia (038.9, Unspecified septicemia), bacteremia (790.7) or urosepsis (599.0, Urinary tract infection, site not specified, or 995.91, Sepsis). These are more serious medical conditions that require IV antibiotic and hospitalization for patients of any age, Lai says.

"The infection will frequently cause encephalopathy with altered mental status and will aggravate any neurological condition the patient already has," Lai adds. "This can cause weakness, confusion, agitation, somnolence and other problems."

Because sepsis and UTI aren't conditions a patient would initially see a neurologist about, your physician will most likely see these patients when he completes a consult for another physician.

"We see it more often in hospital consultations when the patient is being treated for another condition but is experiencing symptoms such as delirium or altered mental status," Lai says. Your neurologist might also be called in to rule out seizure or other neurological-related conditions for a particular patient.

When your neurologist sees the patient during an inpatient consult, report the encounter with the appropriate code from 99251-99255 (Inpatient consultation for a new or established patient ...).

"If the patient is agitated or confused, we might prescribe medications to help," Lai says. "Otherwise we don't normally order medications for the patient but advise the other physician regarding appropriate treatment."

"Any new illness will make a patient's chronic neurological illness seem to be worse," adds 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. "The primary-care physician will address the medical issues, and we will address the neurological ones."

Septicemia or UTI will not be a primary diagnosis for a neurologist, so ICD-9's coding guidelines aren't written with your physician in mind. Instead, the guidelines are written in general terms for an admitting/attending physician (such as a primary-care or internal medicine physician), says Sue Sluder, CPC, CPC-P, professional fee coder/physician billing specialist for Baylor College of Medicine's neurology department in Houston.

Consider this real-life example of a case Sluder recently coded:

Example: A patient with a history of traumatic brain injury (an incident in 1993) presents with altered mental status and infection at the site of a ventriculoperitoneal (VP) shunt with baclofen pump with suspected cellulitis.

The primary diagnosis is 780.97 (Altered mental status). You report 996.63 (Infection and inflammatory reaction due to internal prosthetic device, implant and graft; due to nervous system device, implant and graft) as secondary because the neurologist is not treating the patient for the infection; this code represents the problem with the VP shunt.

You-ll also list V15.5 (Other personal history presenting hazards to health; injury) as a tertiary diagnosis representing the history of traumatic brain injury and include 854.00 (Intracranial injury of other and unspecified nature; without mention of open intracranial wound; unspecified state of consciousness) to specify the type of injury.

"In this case, the physician wrote -sepsis- on the fee ticket, although the medical record did not mention sepsis," Sluder says. According to ICD-9 guidelines, "Either the term sepsis or SIRS must be documented to assign a code from subcategory 995.9." In the example case, the physician's documentation did not include the term "sepsis" so the coder did not report it.

Encephalopathy note: Many charts include documentation of encephalopathy, Sluder says. Because ICD-9 includes a range of diagnosis codes for encephalopathy, verify the patient's condition with your neurologist before proceeding. Your most frequent choice will probably be 348.31 (Metabolic encephalopathy), which can include electrolyte abnormalities, infections, medication interactions and more.

Physicians -- and coders -- sometimes use the terms urinary tract infection (UTI), sepsis and septicemia interchangeably, but that mindset isn't entirely accurate. Learn these definitions from Stedman's Medical Dictionary to ensure you understand the terms: 

- Sepsis: The presence of various pathogenic organisms, or their toxins, in the blood or tissues.

- Septicemia: Systemic disease caused by the spread of microorganisms and their toxins via the circulating blood; formerly called "blood poisoning." (Septicemia is a common type of sepsis.)

- Urinary tract infection: Microbial infection, usually bacterial, of any part of the urinary tract.

A diagnosis of UTI means the patient has bacteria growing in the bladder. Septicemia, on the other hand, is more systemic; infection is present in the patient's blood, which is a more serious condition.