Neurosurgery Coding Alert

Key: Check laceration size and report the office visit.

When your surgeon evaluates and treats a head-injured patient as an emergency case in the office, you’ll be forfeiting deserved payment if you report the service and miss the evaluation.

Example: You many read that a 5-year-old child who had a head injury while playing in the school ground was brought to the surgeon’s office and seen on an emergency basis. Your surgeon does a physical examination and focuses on a detailed neurological examination to look for focal findings from the head injury. Your surgeon documents a laceration in the scalp and provides superficial suturing for the laceration. Here’s what to do:

1. Confirm Laceration Size

Check the clinical note to confirm the size of the laceration. CPT® lists codes for laceration repair of head and scalp, depending on size of the laceration. Depending upon the size of the superficial wound, you report one of the following codes:

• 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less)
• 12002 (…… 2.6 cm to 7.5 cm)
• 12004 (…… 7.6 cm to 12.5 cm)
• 12005 (…… 12.6 cm to 20.0 cm)
• 12006 (…… 20.1 cm to 30.0 cm)
• 12007 (…… over 30.0 cm)

2. Report the Office Visit

You also report code 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient’s and/or family’s needs. Usually, the presenting problem[s] are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family) for the problem focused history and examination that your surgeon does.

If, however, your surgeon does an expanded examination and spends more time with the patient and/or family, you report code 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: …… Usually, the presenting problem[s] are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family) or 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: ….. Usually, the presenting problem[s] are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family) depending upon whether 20 or 30 minutes are spent with the patient and/or family.

"If most of the time in the encounter is spent in counseling the patient and parents and/or coordinating aftercare with the pediatrician, you may be able to report the visit level based upon time rather than the documented three key components," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

You 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 code for office visit to be specific for the E/M.

3. Don’t Forget the Emergency Services

Since the clinical note mentions that your surgeon is treating the patient as an emergency case, you also report the emergency services with code 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service). "While this may be reported, keep in mind that payers may not provide payment for this service," says Przybylski.