Neurology & Pain Management Coding Alert

Coding for the administration of t-PA to stroke victims continues to be a complicated operation for many neurologists. Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pennsylvania Medical Center at Shadyside in Pittsburgh, says that 37195 (thrombolysis, cerebral, by intravenous infusion) is the proper code to use when administering the t-PA medication, though it is for administration only and has no physician work value. The physician is reimbursed for evaluation and management (E/M) of the stroke patient receiving t-PA.

Busis says that the American Academy of Neurology (AAN) published a recent report stating that a large number of E/M codes could be used by the neurologist in addition to 37195 for t-PA administration provided the appropriate key components of an E/M service are met. Possibilities, depending on the circumstances, include:

1. Critical care services (99291-99292)
2. Prolonged care services (99356-99357, 99358- 99359)
3. Initial inpatient care (99221-99223)
4. Initial and follow-up consultation codes (99251- 99255, 99261-99263)

Using Critical Care Codes

Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting in Manassas, Va., reports that many physicians use critical care codes for hands-on care given to patients during and after the t-PA infusion, generally in an intensive care unit (ICU) or emergency room setting.

Castillo says that many physicians feel a t-PA patient meets all the criteria for critical care because he or she has suffered a stroke. Intravenous t-PA administration in stroke victims has a 12 percent risk of fatal cranial hemorrhage, another justification for the use of critical care codes.

Time spent interviewing family members who may possess vital information about the condition of the stroke victim when he or she was found would count toward critical care if the patient is incapable of communication. Any such conversations, however, must occur on the floor or unit to qualify as critical care time.

The correct coding for critical care depends on the total amount of time the physician spends treating the critical patient. Code 99291 is appropriate for the first 30-74 minutes, and 99292 for each additional 30 minutes. If the time spent at the patients bedside overseeing or administering hands-on critical care is spread throughout the day, the cumulative time should be considered and the appropriate critical care code(s) reported.

Neurologists should remember to carefully document the nature and amount of time critical care is delivered to a patient. According to CPT 2000, the time that can be reported as critical care is the time spent engaged in work directly related to the individual patients care whether that time was spent at the immediate bedside or elsewhere on the floor or unit. The AAN report makes it clear, however, that time spent simply being present in the patients room or at the station in case a problem develops or overseeing intermittent monitoring but otherwise engaged in activity not directly related to the patients critical care, does not qualify as critical care.

CPT 2000 further states, For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

A critical illness or injury is defined as one that acutely impairs one or more vital organ systems so that the patients survival is jeopardized. The care of such patients involves decision-making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple vital organ system failure or to prevent further deterioration. It may require extensive interpretation of multiple databases and the application of advanced technology to manage the patient.

Billing Initial Inpatient Care

T-PA must be administered within three hours of the onset of stroke. If the neurologist also has admitted the patient to the hospital, the neurologist appropriately can bill an initial hospital care new or established patient code (99221-99223). The highest level a neurologist likely will use for a stroke victim is 99223 (initial hospital care with comprehensive history, comprehensive examination, and medical decision-making of high complexity), so long as complete documentation is available.

The time spent admitting the patient should not be billed toward critical care. Also, physicians should send in full documentation to justify the admission codes and the critical care codes because some carriers will not pay for critical care codes on the same day as hospital admission. Sending complete documentation may reduce the chance of denials and the necessity for a claims appeal.

Prolonged Service Codes Are Key

If the patients condition does not warrant actual constant bedside and unit work related to the patients critical care, the prolonged service codes (99356-99357 for face-to-face, 99358-99359 for non-face-to-face) might be more appropriate for reporting time spent with a patient receiving t-PA administration. These codes could be billed in addition to the hospital admission code and also would not include time spent admitting the patient. These codes are time-driven; 99356 and 99358 should be used for the first hour of care, while 99357 and 99359 should be billed for every additional 30 minutes of service.

For initial consultations performed in the emergency room or on the hospital floor, codes 99251-99255 should be used for initial consultations and 99261-99263 for follow-up consultations provided the physician does not assume primary care. The neurologist typically spends 110 minutes for a top-level consultation in either situation. To bill for additional time, the neurologist could use prolonged service codes if the appropriate time elements are met.