Neurology & Pain Management Coding Alert

Answer: Codes 99244 (office consultation for a new or established patient requiring a comprehensive history, a comprehensive examination, and medical decision-making of a moderate complexity with counseling and/or coordination of care with other providers or agencies provided consistent with the nature of the problem[s] and the patients and/or familys needs; usually the presenting problem[s] are of moderate to high severity and physicians typically spend 60 minutes face-to-face with the patient and/or family) and 99255 (initial inpatient consultation for a new or established patient requiring a comprehensive history, a comprehensive examination, and medical decision- making of high complexity with counseling and/or coordination of care with other providers or agencies provided consistent with the nature of the problem[s] and the patients and/or familys needs; usually the presenting problem[s] are of moderate to high severity and physicians typically spend 110 minutes at the bedside and on the patients hospital floor or unit) both fall under the evaluation and management (E/M) section of CPT 2000.

Catherine G. Fischer, CPA, reimbursement policy advisor for the Marshfield Clinic in Marshfield, Wis., a regional healthcare system with 650 physicians and more than 50 specialties including neurology, says if two distinct services are provided and documented, then it is important to bill for both, appending the -25 modifier (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, which indicates that a separate and significant evaluation has been provided in addition to the procedure. Please note that some testing already is included in the E/M neurological examination. Evaluation of higher integrative functions including: orientation to time, place and person, recent and remote memory, attention span and concentration, language (e.g., naming objects, repeating phrases, spontaneous speech), fund of knowledge (e.g., awareness of current events, past history, vocabulary), according to the Health Care Financing Administrations (HCFA) E/M documentation guidelines released in November 1997.

Therefore, if the overall testing exceeds the testing cited in the E/M neurological exam and is aptly described by the wording in CPT code 96115 (neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning] with interpretation and report, per hour) and the neurologist documents this additional testing and the time spent performing this service (96115 is time-based), the neurologist should bill for both the E/M and the testing code, appending modifier -25 to the E/M.

Because the E/M codes are the domain of physicians, and 96115 falls under 96100-96117a range of testing codes usually viewed by carriers as the domain of psychologists, neuropsychologists, and other healthcare professionalspayers may limit who should be paid for these services. Neurologists must submit clean claims, ranking the order of diagnosis codes and linking them to the CPT codes. Physicians also must document the separateness of the services, anticipating the request to review the documentation. In some situations, physicians may need prior authorization to provide services.

Chavonda Darby, RA, reimbursement coordinator for more than 40 neurologists in the department of neurology at the Emory Clinic in Atlanta, reports that she has been dealing with exactly this difficulty when billing for 96115. Darby uses diagnoses codes that are appropriate for the conditions being treated and has received denials in part because these diagnoses codes are linked to health issues and not mental health issues.

Another potential point of confusion for carriers is that 96115 occasionally is billed by neurologists to describe what is often called a mini mental exam. The components of a mini mental exam are duplicated under the description of the E/M requirements, so some carriers who see a 96115 billed with any E/M code automatically will issue denials because of duplication of service. But a true neurobehavioral status exam, for example, those performed by a pediatric neurologist, may necessitate more than three hours spent with a patient. The documentation of time and service is especially important to help carriers understand the difference between a full blown neurobehavioral status exam and a mini mental exam.