Neurology & Pain Management Coding Alert

The deletion of modifier 21 (Prolonged evaluation and management services) and the revision of prolonged services codes in CPT 2009 has the entire coding industry talking. The impact of these changes on your neurology coding should be mostly positive -- particularly when reporting inpatient prolonged services.

As you-ve probably noticed, Medicare's current policy for reporting -inpatient prolonged- is at odds with the AMA's CPT 2009 definitions.

The CPT revisions are -a beautiful clarification that will allow physicians to see their patients more than once a day in the inpatient setting, and use prolonged services codes if the compilation of visits during the course of the day allows it,- says Joan Gilhooly, CPC, CHCC,president of Medical Business Resources in Chicago.

Just before the start of 2009, Neurology Coding Alert reported an update to +99356 (Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour [List separately in addition to code for inpatient evaluation and management service]). This code replaced the deleted phrase regarding direct (face-to-face) patient contact with a -unit/floor time- requirement. CPT also deleted an example in the code description. Historically, using time as the basis for a level of an inpatient E/M service was not a face-to-face requirement but rather a unit/floor time requirement. CPT revised the prolonged service code description to match the requirement for those applicable E/M codes.

Take note: Medicare statutorily still requires the faceto-face criteria for prolonged services. In 2009, there is a mismatch between the CPT code descriptors and Medicare policy for the inpatient prolonged services. AMA guidelines allow you to count -floor/unit time- when considering inpatient direct prolonged service codes. Doctors can bill for unit/floor time for such activities as reviewing medical records, documenting, and discussing the case with other involved providers on the floor and at the nurses- station.

The new CPT language for +99356 and +99357 (... each additional 30 minutes [List separately in addition to code for prolonged physician service]) is not consistent with Medicare's policy for these codes.

-Medicare will pay for prolonged physician services [code 99356] with direct face-to-face patient contact,which require one hour beyond the usual service,-according to MLN Matters article MM5972 www.cms.hhs.gov/MLNMattersArticles/downloads/MM5972.pdf). The article also says you cannot count any time not spent face-to-face with the patient, such as patient chart review or discussion with other providers, toward prolonged service coding in the hospital setting.

The deletion of modifier 21 should make things easier for coders when considering prolonged service codes,experts say. Often, -providers and billers would forget that modifier 21 was allowed only for the highest-level E/M code in a category,- recalls Lynn A. Brown, CPC, director of physician coding and reimbursement at CHS in Birmingham, Ala. And remember, per CPT 2008, Appendix A, you would use the modifier only on an E/M code.

You should code the level of care based on the E/M service provided and documented, including not only the three key components, but also medical necessity and time if appropriate. For Medicare, report prolonged E/M services, +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-toface] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient evaluation and management service]) or +99356, if the total duration of the provider's face-to-face service equals or exceeds 30 minutes beyond the established E/M service time for the level of direct patient care provided.

For example: Your neurologist sees a patient, and the E/M medical necessity level for the visit meets the criteria for 99214 (Office or other outpatient visit for the evaluation and management of an established patient,which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ... Usually, the presenting problems are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family). The visit takes 70 minutes.

This visit would be eligible for an additional prolonged service code of +99354 with 99214, Brown says.

When you report office-setting prolonged service codes (+99354 and +99355, ... each additional 30 minutes [List separately in addition to code for prolonged physician service]), the patient and provider must meet face-to-face during the encounter, Gilhooly says. But the inpatient prolonged service codes substitute -face time- with -unit/floor time.-

According to new CPT notes for +99354 through +99357, -Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes.- Loss of payment on soon-to-be-included prolonged services, however, will probably not be widespread. Many payers often did not recognize modifier 21 for additional payment, according to Brown.

You don't need to send the patient's medical record documentation with the bill for prolonged services. The exception to this is if you-ve been selected for medical review.

The MLN Matters article, however, states, -Documentation is required to be in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services that you bill.-

In other words: You must sufficiently document in the medical record that your neurologist personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. Document not only the date of service but also the start and end times of the visit.