Neurology & Pain Management Coding Alert

Many neurologists see patients in a variety of inpatient and outpatient settings, and many of these patients are covered by a wide array of health plans. In addition, neurologists and neurology billing and coding companies may submit claims for patients who are visiting the area but have insurance coverage in different cities and different states.

Billing requirements and policies often differ from payer to payer. Karen Duane, CPC, coding specialist for the Barrow Neurological Institute, which has 20 neurologists in Phoenix, says that different carriers and third-party payers may have varying guidelines about what conditions warrant epidural blocks (62310-62311, 62318-62319, 62280-62282, and 64479-64484), so it is important to keep track of local carrier rules.

Rhonda Petruziello, CPC, reimbursement specialist for the Cleveland Clinic Foundation in Cleveland, says that some insurance companies recognize a certain way of billing. On the HCFA 1500 form, some carriers want you to line itemize each charge because they do not recognize quantity designators, whereas other carriers may say to group it all into one code and put the quantity amount.

Some insurance carriers have electronic billing software that is not equipped to read anything more than a five-digit CPT code, Petruziello adds. In these instances, it is necessary to submit a hard copy claim to ensure that the carrier understands what is being coded. Knowing the carrier-billing format at the beginning of the patient billing process if the carrier recognizes modifiers can save time and money for neurologists submitting claims.

Medicare carriers have different policies in different regions. In North Carolina on any new patient (99201-99205) visit, Medicare does not want to see the -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on an evaluation and management (E/M) when a procedure is performed, says Pat Moore, vice president of reimbursement for Healthcare Business Resources Inc. (HBR) in Durham, N.C. They expect you to bill an evaluation and management (E/M) code and a procedure, but they tell you not to use the modifier because it will bounce out on their edits for having too many -25 modifiers. But in Florida, coders have to use the -25 modifier for Medicare.

How to Create a Carrier Log

Setting up a strict coding policy that does not take these differences into account can mean lost revenue and even lost payer contracts. To keep track of different policies and ensure that their physicians get accurately reimbursed, Moore has set up a system called Coding Considerations at HBR.

Coders for neurology are urged to keep a log for every one of their clients. This log should include sections on all of the payers neurologists contract with, listing what diagnosis codes they accept for epidural blocks or if there are restrictions, whether codes should be line itemized, if modifiers are recognized, etc.

When a coder looks at a chart, he or she focuses on the considerations listed for that payer and that specific physician group. The system is comprised of a set of three-ring binders that is maintained by a specific set of staff members at HBR.

In the binder, in addition to the coverage information, we have the back-up for that instruction, whether it was a Medicare bulletin or a page from the CPT Assistant, she says. All of that is in the back of the book. And, any time new information comes in, upper management signs off on it and then it is added to the books.

This system allows coders to easily tailor their coding to the specific payer requirements, saving money and lost time spent on appeals. When someone is coding our charts, they have the coding considerations right there and can anticipate when billing what will or will not be paid, or the right way to submit a claim for immediate reimbursement, Moore says.

Neurologists wanting to take a more active approach may negotiate language in their managed care contracts that specifies claims processing policies and standards for key procedure codes.

When evaluating electronic billing software systems for your practice, see if there is an option to create a coding considerations database within the software so that the considerations can be linked to the applicable patient records, or consider keeping a coding considerations logs in a stand-alone electronic database.