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 [...]