Neurosurgery Coding Alert

Report symptoms documented and do not ignore late effects.

When you're coding your surgeon's concussion services, you could be sidelining your claims if you're omitting E/M work or missing the right diagnosis codes. Learn about three common myths that could be stalling your pay.

Myth 1: Don't Bill Anything besides E/M

Before you've got your diagnosis code nailed down, you'll focus on the appropriate CPT® code to describe your service. If the physician provides an outpatient E/M service to evaluate the concussion, you'll report the appropriate code from the 99201-99215 series. But although many practices think that's where the coding ends, you may be able to report additional services, depending on what the physician does.

If your physician administers a computerized neuropsychological test to determine the impact of the concussion, you report 96120 (Neuropsychological testing [e.g., Wisconsin Card Sorting Test], administered by a computer, with qualified health care professional interpretation and report).

If your physician performs both the neuropsychiatric testing and the E/M service at the same session, you can report both codes, assuming that your documentation can demonstrate the separate nature of the two services. In that case, you'll append 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) to the E/M code.

"In order to report both the E/M service and the procedure, the decision to perform the testing must be based on the findings obtained through the E/M service itself," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison. "The E/M service would not be reportable if the purpose of the visit was to perform the test alone."

Often, concussion patients will return for follow-up visits. You can report the appropriate E/M code for these visits, unless the physician performs a different service besides an E/M. For instance, if he saw the patient shortly after the concussion and the patient's only symptom was blurred vision, the doctor might want to administer a vision test after two weeks pass. If the vision test is the only reason for the visit, you'll report the appropriate code for that service.

Myth 2: You Are Limited to the Dx of 959.01

If your physician is called in to see a patient with a head injury, you need to get straight what's involved with coding these events from a diagnosis standpoint. However, you can't simply default to 959.01 (Other and unspecified injury to head)-another code might be more appropriate consistent with the documentation.

Minor injuries: If the patient has a contusion to the head, you should use 920 (Contusion of face, scalp, and neck except eye[s]), but remember that a contusion, by definition, refers to an injury that does not break the skin, including a bruise. You should check for exclusions in your ICD-9 book. The exclusion note for 920 refers to various other codes for more significant injuries that go beyond a basic bump on the head.

Significant injuries: You should report codes from the 850-854 series, including 854.01 (Intracranial injury of other and unspecified nature; without mention of open intracranial wound; with no loss of consciousness), for specific and serious injuries involving the head, such as concussions, cerebral lacerations, cerebral contusions, and open wounds with brain hemorrhage. This series represents very serious injuries resulting from high-energy impacts to the head. Specifically, the 854 set includes cavernous sinus and intracranial injury. The series maps to S06.- - series in ICD-10. "You should use the most definitive diagnostic code available," Przybylski says. "Often, patients sustaining a concussion will have a period of loss of consciousness. The duration of loss of consciousness allows greater specificity in the diagnosis chosen. There are diagnoses for concussion that are divided among those without imaging evidence of intracranial injury as well as those with open or closed fractures with or without intracranial injury."

When your provider doesn't document any further detail than "head injury," you should use 959.01. This code also has a list of exclusions similar to 920.

Myth 3: Late Effects Codes Don't Apply

Although some practices think late effects codes are a one-way ticket to denial, the opposite is true. Late effects codes can help you bolster your claims and collect faster. If the patient had a brain injury more than a year ago, you should look to a late effects code, which creates the causality relationship between a prior injury and the current condition your provider is treating.

A possible example is 907.0 (Late effect of intracranial injury without mention of skull fracture). In addition, you want to code as primary the actual residual condition for which the physician is seeing the patient, such as cognitive changes.

What it is: A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has ended. There is no time limit on when you can use a late effect code. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to a previous injury. In some patients, this may be residual dizziness or double vision following a concussion or specific cognitive deficits.

Coding late effects generally requires two codes sequenced in the following order: first, the condition or nature of the late effect; and second, the late effect code. For instance, the condition code could be confusion (293.1, Subacute delirium), followed by 907.0.

Reporting acute injury codes for all of the subsequent services for the latent/residual condition from a single injury indicate that the patient has had repeated acute injuries rather than requiring treatment/care for the delayed recovery of the initial injury.

"Consequently, one should only report acute injury code(s) at the time of the initial injury and when the acute consequences of that injury are being treated," Przybylski says.