Neurology & Pain Management Coding Alert

Look to critical care first: The code category you choose depends on individual circumstances, but critical care codes are a good place to begin.
 
CPT requirements for critical care are strict, but patients requiring t-PA will almost always qualify.
 
"Making the decision to give t-PA is an element of critical care medicine," Saver says. In trials, "t-PA was associated with a symptomatic hemorrhage rate of 6.4 percent. Thus, about one in 17 patients who receive t-PA will have some degree of brain hemorrhage associated with some degree of worsening," he continues. "Only 38 percent of patients will achieve a good functional outcome if untreated. They are at risk for brain hemorrhage, seizure, cerebral herniation, pneumonia, pulmonary embolism, and numerous other acute neuromedical complications."

What is t-PA? Tissue plasminogen activator, more commonly known as t-PA, helps to dissolve blood clots and restore blood flow. When taken intravenously, the drug has been shown to decrease the chances of debilitating injury and neurological damage for stroke victims if administered within three hours of the stroke episode.
 
Because the drug is an anticoagulant, providing t-PA to a patient with bleeding in the brain can cause a fatal hemorrhage. Therefore, the neurologist must order a computed tomography scan of the head prior to giving the medication to be sure the patient doesn't have intra-cranial bleeding.

Note the Time Precisely for Critical Care

The key to reporting critical care for t-PA patients is to document exactly the time the neurologist spends administering the drug and monitoring the patient.
 
Report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 30-74 minutes of critical care services (for fewer than 30 minutes of critical care, select a different E/M category). You may claim +99292 (...each additional 30 minutes [list separately in addition to code for primary service]) for each additional 30 minutes beyond the first 74 minutes.
 
Neurologists can count time spent talking to the patient's family toward critical care (this is important because the victim may be unable to communicate), but they cannot use critical care codes for time spent "on-call" for changes in the patient's status, such as blood pressure or neurological signs, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., in Brick, N.J., and a member of the AAPC National Advisory Board.
 
Example: A patient's daughter brings him to the emergency department, claiming that he showed symptoms of stroke 30 minutes before. The neurologist examines the patient, orders a CT scan and, after discussing the benefits and risks with the daughter, decides to proceed with t-PA. The total time of critical care is two hours.
 In this case, you may report 99291 (for the first hour of critical care) and 99292 x 2 (for the additional hour or critical care). If the neurologist also interpreted the CT scan, you may bill separately using 70460-26 (Computed tomography, head or brain; with contrast material[s]; Professional component)

Prolonged Services Provide an Alternative

If your documentation will not support critical care, but the neurologist spends extensive time with the patient, you may turn instead to prolonged service codes.
 
Like the critical care codes, prolonged services are time-sensitive, and you should record all time precisely. Report +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour [list separately in addition to code for inpatient evaluation and management service]) for the first hour  and +99357 (...each additional 30 minutes [list separately in addition to code for prolonged physician service]) for each additional 30 minutes beyond the first hour.

You'll Need to Add Hospital Admission

Because the neurologist usually orders t-PA on the patient's first day in the hospital, you should report a hospital admission code (for example, 99223, Initial hospital care ... with a comprehensive history, comprehensive examination, and medical decision-making of high complexity, if the physician has appropriate documentation) in addition to the critical care or prolonged services codes.
 
Admission time is separate from critical care or prolonged services: You should not count the time the neurologist spends on the hospital admission toward either critical care or prolonged services, Cobuzzi says.
 
For example: The neurologist spends 40 minutes evaluating the patient prior to admission. He then spends an additional hour with the patient monitoring him during the CT scan and t-PA administration.
 In this case, the 40 minutes spent evaluating the patient count toward the hospital admission (99223). You cannot count this time again toward the prolonged services total. For the prolonged services, report 99356 (for one hour of prolonged services), in addition to the admission.
 
Only the admitting physician may use the initial care codes per patient per hospital stay. If the neurologist tends to the patient following admission and E/M by another physician, the neurologist must report the subsequent hospital care codes (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) unless the service meets the specific requirements for a consult (see next article).