Neurosurgery Coding Alert

When you open your CPT 2008 manual, you-ll be confronted with a dozen new evaluation and management codes, along with fewer deletions and some minor revisions. Here's the information you-ll need to adapt your E/M coding when Jan. 1 rolls around.

Fully half the new E/M codes are replacements for codes removed from CPT 2008. For instance, medical team conferences codes 99361 and 99362 have been deleted and replaced by three all-new codes:

Codes 99366-99368 differ from their predecessors 99361 and 99362 in several ways. Most important, 99366 and 99368 apply to nonphysician healthcare professionals (NPPs), such as a nurse, nurse practitioner, physician assistant, etc. Both code descriptors specify a minimum service time of 30 minutes or more, but 99366 also stipulates that the patient and/or family be present during the conference.

"Codes 99366-99368 were added to allow inclusion of nonphysician, qualified healthcare professionals," says Susan E. Garrison,-CHC, PCS, FCS, CCS-P, CPAR, CPC,-CPC-H, executive vice president of Healthcare Consulting Services.

Patient presence matters: Many payers, including Medicare, will not reimburse separately for non-face-to-face services -- which means insurers will likely not recognize 99368 (during which the patient and/or family is not present) as a payable service. There is a possibility, however, that payers may accept 99366 if an NPP in your practice takes part in a team conference for a patient in your care, as long as the patient and/or family is involved.

Code 99367 also requires a service time of 30 or more minutes, but applies when a physician (rather than an NPP) participates in the team conference. In this case, the patient and/or family are not present.

Previous codes 99361 and 99362 also described physician participation in a team conference, but because those codes specified "patient not present," Medicare and other payers would not reimburse for the services. Because 99367 is likewise not a face-to-face service, payers will almost definitely not pay for it.

Reporting advice: Documentation will be key when reporting team conferences, Garrison says. She suggests that for each service, physician notes should specify:

- Who participates in the conference (the specific providers with credentials).-Only one same-specialty, same-practice professional may bill per conference.

- Time of participation.-This must begin at the start of the review for an individual patient, and ends when that review concludes. The service must deal with one patient at a time.

- The patient's presence (or lack thereof).

- The plan going forward, to include:-

- goals of treatment

--what rehab treatment is prescribed (be specific)

--any referrals.

CPT 2008 does not contain a code for a team conference with both the physician (rather than NPP) and the patient and/or family involvement. In such a case (that is, when both a physician and patient are present for a counseling service), the physician should report a standard E/M code (such as an established patient visit 99212-99215) based on counseling and coordination of care time, Garrison says.

"Be sure to alert your physicians," Garrison says, "that counseling and coordination of care time must be recorded in the documentation."

CPT 2008 will add reference times to several E/M code categories -- specifically nursing facility care (99304-99310) and annual nursing assessments (99318) -- that did not previously include them.

Although neurosurgeons will infrequently provide these services, the addition of a reference time means that, when necessary and supported by documentation, you may select an E/M service level using time (rather than the key components of history, exam and medical decision-making) as the primary deciding factor.

The AMA has updated and replaced the telephone service codes several times in the past few years, and once again in 2008, you-ll have all-new codes -- with fresh descriptors -- to apply for these services:

Previous telephone service codes 99371-99373 (deleted for 2008) described a "telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other healthcare professionals." The precise services named by the new codes listed above are considerably narrower: the telephone service must be unrelated to any previous service within the past week, and the telephone service should not lead to a face-to-face evaluation within the next 24 hours.

Medicare and other payers have categorically refused to pay for telephone services. Skilled coders knew, however, that you could consider telephone conversations between a physician and patient as a factor when determining a service level for any related E/M service -- if the physician's documentation showed how the telephone conversation affected the key components of history, exam and medical decision-making.

Presumably, you will continue this practice in 2008, and CPT will no longer contain a code for reporting telephone services that are related to a recent E/M service or that immediately result in an E/M service for the same complaint. But in cases when a telephone service is unrelated to any recent or resulting E/M services -- that is, the telephone service is truly independent and therefore not counted as a part of any other service -- you can call on 99441-99443.

"Although these codes are primarily reported based on the time spent communicating with the patient, proximity of in-office services will also determine whether the call can be charged," says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga.

Physician documentation will almost certainly have to verify the content and significance of the conversation, as well as its length (99441-99443 are time-based codes).

Good news: "I think that time-based reporting versus trying to determine what is -simple,- -intermediate- or -complex- [the criteria for telephone service prior to CPT 2008] is definitely a good thing," says Denae M. Merrill, CPC-E/M, coder for Covenant MSO in Saginaw, Mich. "You then have a clear-cut definition of what is what, a provider will then know what is important to document, and a coder will know what code is most appropriate, and there will be no room for arguing."

Potential bad news: Although the AMA has redefined the telephone codes once again, they remain, by their very nature, non-face-to-face services, and therefore risk continued non-payment.

"Remember: Even if the service is billed, it may not be reimbursed by insurance," Parman says.

"The medical necessity of physicians handling issues over the phone is rarely supported for additional reimbursement in payers- minds," Garrison says.

For 2008, if you wish to report a physician/patient "e-visit" -- essentially an on-line, non-face-to-face E/M service occurring via e-mail, instant messaging, etc. -- you may turn to new code 99444 (Online evaluation and management service provided by a physician to an established patient, guardian, or healthcare provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network). Code 99444 will replace Category III code 0074T, which previously described an e-visit but has been deleted for 2008.

As with telephone service codes 99441-99443, you should apply 99444 only if the e-visit is unrelated to any previous service within the past week. Also, you will want to be sure that the physician develops separate documentation to show that the e-visit is significant and independent of other recently provided services.

"It appears that both the telephone services and online services would only be reported if they took the place of a visit," Parman say. "Many insurance payers have not embraced this service for reimbursement, and there are technology requirements (HIPAA-compliant network, retention of online conversation in permanent patient record, etc.) that also have to be met."

In addition, e-visit patients must be established -- you cannot apply 99444 for a new patient.

Keep watching: "New codes, or codes transitioned from Category III to I, do not mean more reimbursement," Merrill says. "It often takes the payer community time to get on the-bandwagon and start reimbursing. Even then, you may find they will create guidelines to limit reimbursement to specified criteria only."

Of the five remaining new E/M codes in CPT 2008, two (99406 and 99407) will deal with counseling patients on how to quit smoking, and two others (99408 and 99409) will describe alcohol and/or substance (other than tobacco) abuse structured screenings and interventions. None of these codes are generally applicable in a neurosurgery practice.

The final new E/M code in CPT 2008, 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or less, who requires intensive observation, frequent interventions, and other intensive care services), describes an admission for a neonate who requires services less intensive than those described by neonatal critical care code 99295, but nevertheless requires constant, high-level care.

Neurosurgery Coding Alert will bring you all the information, as it becomes available, on payer reactions to team conferences 99366-99368, telephone service codes 99441-99443, e-visit code 99444 and others.