Neurology & Pain Management Coding Alert

Limit reporting of 96116 under NCCI 12.0

Neurology coders rejoiced when CPT 2006 created new codes for neurobehavioral status exams--but be prepared for the first round of NCCI edits to rein in your coding options.

Count 96116 as E/M Component

When CPT 2006 introduced a new code for neurobehavioral status exams, many neurology practices hoped it would convince payers to consider the service distinct and separately reimbursable from evaluation and management visits.

But NCCI version 12.0, which took effect Jan. 1, says you-ll need to justify separately identifiable services to report any E/M service along with 96116  (Neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities], per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report).

So despite the new code, your reporting options are very similar to how you-ve handled neuro-status exams in the past. -The previous CPT code, 96115, for this type of service was likewise bundled into the vast majority of E/M codes,- says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a consulting firm in Denver.

Key difference: The difference between the former code for this service (96115) and 96116 won't dictate how you bundle, but rather how you calculate time. With 96116, you count both face-to-face time with the patient and time spent interpreting and reporting results by a physician or psychologist--not a technician, Hammer says.

Unbundle With Care

The status indicator of -1- for these bundles signals that separate reporting of 96116 and E/M codes is allowable when you are able to document a significant and separately identifiable E/M service, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

In such situations, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to make your case for separating the edit.

Example: It might be appropriate to unbundle a neuro-status exam in the case of  -two separate encounters on the same date of service with neurobehavioral testing including interpretation and report in the morning and initial hospital care provided by the neurologist following a hospital admission later in the day and under a different diagnosis,- Hammer says.

Bottom line: If you are able to successfully unbundle 96116, you can expect an average nonfacility payment of $103.83 for the service, based on the 2.87 relative value units assigned to the service in the 2006 Medicare Physician Fee Schedule.

While the bundling of neuro-status exams and E/M procedures is the most encompassing edit for the new testing codes, review the table to see what other bundles could trip up your coding.

Update your links: To access the full database of NCCI edits, go to www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.