Neurology & Pain Management Coding Alert

Question: A new patient reports to the neurologist with head tilt to the left and eye deviation (eyes are not symmetrical on the patient’s face). After an evaluation and management (E/M) service that involves moderate medical decision making (MDM), the physician orders a magnetic resonance imaging (MRI) of the brain stem without contrast material. Upon viewing the MRI, the neurologist diagnosis the patient with ocular torticollis. How should I report this encounter, and what is ocular torticollis?

Maine Subscriber

Answer: On your claim, report:

• 70551 (Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material) for the MRI
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care profes­sional on the same day of the procedure or other service) appended to 99204 to show that the E/M and MRI were significant, separately identifiable services
• R29.891 (Ocular torticollis) appended to 70551 and 99204 to represent the patient’s condition

Condition definition: Ocular torticollis is also referred to as ocular tilt reaction or skew deviation. The condition is characterized by abnormal positioning of the eyes and head; this is due to imbalances in the ocular muscles or the vestibular system.

Patients suffering from ocular torticollis will often present with head tilt or deviation of the eyes, as the patient in your scenario has. Other symptoms of ocular torticollis include:

• Double vision (diplopia)
• Difficulty focusing
• Neck discomfort or pain
• Nausea and dizziness
• Visual disturbances.