Neurosurgery Coding Alert

Counseling could lead to time-based E/M coding

When you code a mini-mental status exam (MMSE), don't make the common mistake of claiming 96115. Rather, you should include an MMSE in any E/M service the surgeon also provides.

Look to Surgeon Notes to Distinguish MMSE

If the surgeon's documentation describes a cursory mental exam lasting 20 or fewer minutes, you cannot charge separately for the service, says Anne M. Dunne, RN, MBA, MSCN, administrator for South Shore Neurologic Associates PC in Long Island, N.Y.

The MMSE is a 30-element examination, originally created to provide a quick and simple summary test, according to CPT Assistant, Volume 10, Issue 10 (October 2000). In general, the MMSE takes less than 15 minutes to perform and interpret, and "was never meant to substitute for more comprehensive testing," CPT Assistant states. Although the MMSE can be a valuable tool to test the mental acumen and awareness of stroke victims, trauma patients and others, CPT does not include a separate code to describe this service.

Another way: If, on the other hand, the surgeon documents an extensive clinical evaluation of the patient's cognitive function (of the central nervous system) lasting one hour or more, you may be able to support coding for 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), depending on the payer.

Requirements for Full Exam

A full neurobehavioral mental status exam (MSE) (96115) involves a much more extensive evaluation of the patient's thinking, reasoning and judgment, Dunne says. Such exams include a clinical evaluation of memory, attention, concentration, motor speed and strength, language functions, visual spatial abilities, and reasoning and judgment. Following an MSE, The clinician would interpret the findings, formulate a diagnosis and make treatment recommendations.

Warning: In most cases, a neurosurgeon would not report a mental status exam (96115) because such a service would be outside his normal scope-of-practice. And some Medicare Part B carriers restrict 96115 to psychiatrists, independently practicing psychologists, and clinical psychologists.

Fold MMSE Into E/M
 
Although CPT does not contain a separate code for MMSE, you can often account for the surgeon's test services by including it in any E/M services the surgeon also provides, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems Inc., which supports family practice physicians in Broomfield, Colo.
 
If the MMSE contributes significantly to the elements of exam, history and medical decision-making, you may report a higher-level E/M service. In particular, an MMSE may raise the "exam" portion of the E/M service.

Example: The surgeon provides a consult for a new patient with memory loss, dizziness and other symptoms, which includes a comprehensive history, a detailed examination and high-complexity medical decision-making.

As a final step to assess the patient, the surgeon conducts an MMSE, which raises the level of this particular examination to comprehensive.

In this case, you can report 99205 (Office or other outpatient visit for the evaluation and management of a new patient ...), rather than the lower-level service 99204.

When Time Is King

Alternative: If counseling and coordination of care consume more than 50 percent of the visit, you may use time as the determining factor when assigning an E/M service level, says Barbara J Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., in Brick, N.J.
 
For instance, the surgeon spends 20 minutes taking the patient's history and performing an exam, and 15 minutes doing an MMSE. He then speaks with the patient about his condition for an additional 45 minutes. In this case, the MMSE will make the difference between 99244 and 99245 (Office consultation for a new or established patient ...).

When reporting E/M services based on time, maintain careful documentation outlining the time spent face-to-face in counseling or coordinating care with the patient or his family.