Neurology & Pain Management Coding Alert

Learn how coding signs and symptoms may raise reimbursement

If you-re faced with assigning diagnosis codes during EEG seizure monitoring, you-ve likely encountered frustration in the chasm between current medical terminology for seizures and ICD-9 definitions. Use some of these expert tips to help overcome frustration and bridge the language gap.

1. Translate Chart Terminology

Epileptologists have spent many years lamenting the limitations of ICD-9's descriptions for epilepsy conditions. -ICD-9 is at least one generation behind, and it's based on a very old understanding of epilepsy,- says Paul M. Levisohn, MD, practice committee chair of the American Epilepsy Society and associate professor of neurology and pediatrics at the University of Colorado Health Sciences Center in Denver.  

But coding a diagnosis to the highest level of specificity is not impossible if you learn to read between the codes.

Terms such as -myoclonic,- -absence- or -partial seizures- may crop up frequently in documentation but appear to be missing from epilepsy code definitions (345.xx). You can get some clarity, however, if you take notice of the terminology below each code's definition, which provides -keywords- that can also refer you to an appropriate diagnosis.

Example: Your neurologist documents a patient presenting with myoclonic epileptic seizures, but you can't find an epilepsy code specifically for this category. Reading through the descriptions following each code, however, you spot myoclonic epileptic seizures under 345.1x (Generalized convulsive epilepsy).  

Use your ABCs: If you-re still stuck with a tough term, you may be able to translate your doctor's description into a diagnosis code using the epilepsy listing in ICD-9's alphabetical index.

For example, if you use the index to look up epileptic seizures caused by cysticercosis, you-ll be directed to 123.1 (Cysticercosis), a code you never would have found combing through the 345 range.

2. Don't Fear Unspecified Codes

Although you may face challenges translating the language in a patient's chart into ICD-9 definitions, you-ll also likely encounter situations when you just don't have enough information to arrive at a specific diagnosis. 

Patients experiencing seizures will often need to undergo EEG monitoring to pinpoint the reasons and to help neurologists localize the portion of the brain affected. In other words, a final diagnosis is most often undetermined at the time of monitoring.

Many coders try to avoid assigning unspecified diagnoses at all costs. But when a definitive diagnosis is not available, you can feel comfortable using unspecified codes to diagnose the patient's seizure activity. Most frequently, coders will look to 345.9x (Epilepsy, unspecified) or 780.39 (Other convulsions).

Even when a neurologist arrives at a specific diagnosis, you may still not be able to report the patient's condition with any current ICD-9 definitions. In such cases, consider using 345.8x (Other forms of epilepsy).

Examples: Diagnoses such as frontal lobe seizures or myoclonic-astatic episodes would fall under 345.8x, Levisohn says.

The good news is that using these unspecified codes when diagnosing seizures will rarely have an adverse effect on a claim's approval or reimbursement levels, Levisohn adds.

Check for a fifth digit: But even with an unspecified code, you may be able to increase the accuracy of your diagnosis. When you-re choosing epilepsy codes from the 345 range, don't forget to check the possibility of adding a fifth-digit subclassification.

With the epilepsy codes, a fifth digit of 1 indicates that the condition is intractable, meaning it is not responsive to customary doses of medication. You should use a 0 as the fifth digit when there is no mention of intractability in the patient's record.

3. Know When to Code Signs and Symptoms

Although more unusual than physiological causes, you may encounter patients who are suffering from seizures as a result of psychological triggers, such as domestic abuse or post-traumatic stress. In such cases, some coders will flip to the 300-316 range (Neurotic disorders, personality disorders, and other nonpsychotic mental disorders) to diagnose these -pseudo-seizures.-  But if this is your first impulse, you could be throwing away significant reimbursement.

Reason: While the final diagnosis is accurate, it does not always represent the signs and symptoms that required the EEG. As a result, your payer may question the medical necessity of the EEG or reimburse an amount that doesn't even recoup the cost of monitoring.

In such cases, you are better off assigning a diagnosis based on the patient's symptoms, such as convulsion code 780.39. Tip: Most signs and symptoms codes are found in the 780-799 range of ICD-9, although there are exceptions, such as 729.5 (Pain in limb).

Caveat: For inpatient coding, if the physician uses terms such as -probable,- -suspected- or -rule-out,- you can code the condition as if it existed, according to ICD-9 guidelines. -The rationale I have received is that the same resources are expended [for inpatients], regardless of whether the diagnosis is confirmed or not,- says Cindy C. Parman, CPC, CPC-H, RCC, president of the AAPC National Advisory Board and principal of Coding Strategies Inc. in Powder Springs, Ga. 

4. Check Allowable Diagnoses for Video EEG

You-ll also want to pick your diagnosis codes carefully when the physician performs video EEG monitoring or VEM (95951, Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic [EEG] and video recording and interpretation [e.g., for presurgical localization], each 24 hours).

This service can be essential for distinguishing epileptic seizures from similar conditions, pinpointing the types of seizures that the patient has, or localizing the portion of the brain in which the seizures are occurring.

Many payers publish their own guidelines and allowable ICD-9 codes for 95951, and you could face denials if you don't contact your insurer for their specifics. Medicare, for instance, first requires the physician to perform a resting EEG before it will grant coverage for VEM. Medicare will not also accept convulsion code 780.39 in conjunction with 95951.