Neurosurgery Coding Alert

Nugget: Neurosurgeons should consider not only history, exam and medical decision-making when determining the E/M service level but also time spent in counseling the patient to maximize reimbursement. Choosing the appropriate evaluation and management (E/M) service level is always challenging. Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, N.J., says that a variety of coexisting conditions may accompany a patient’s presenting complaint. When coexisting conditions and the time spent
counseling the patient and/or the patient’s family are not taken into account, a physician may end up charging for a lower E/M level than he or she could.

Uncovering Coexisting Conditions

As physicians know, coexisting conditions may not be immediately apparent. They often will turn up during the history-taking component of the initial patient encounter. The information about coexisting conditions may come from the patient, the patient’s family or previous medical documentation. “For neurosurgeons, the initial encounter is typically reported using E/M consultation codes (99241-99245 for
outpatient, or 99251-99255 for inpatient), because the patient has already been identified by the primary-care physician or other specialist as a surgical candidate,” reports Rhonda Petruziello, CPC, reimbursement specialist for neurosurgery at Cleveland Clinic Foundation in Cleveland. Using the consultation E/M codes means that another physician requested the consult and that the
consulting neurosurgeon renders a medical judgment and submits a written report to that physician detailing the encounter and findings.

Note: If the physician requesting the consultation and the neurosurgeon performing the consultation share a chart for this patient, written documentation in that shared chart can substitute for a separately submitted written report.

Within the entire history component, there is a chief complaint, history of the present illness, review of body systems or areas, and a past/family/social history. Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., says the neurosurgeon may uncover a variety of coexisting conditions, such as malignant hypertension (401.0), insulindependent diabetes (250.01), congestive heart failure (428.0) or respiratory cardiovascular problems during the review of systems portion of the history-taking. “The complexity and number of coexisting conditions uncovered during the history may dictate how detailed an examination he or she will need to perform,” she reports.

The neurosurgeon may choose the appropriate E/M level to bill for the visit in two ways. The physician may review the documented history that was taken from the patient and family, the exam that was performed on the patient, and the medical decision-making that was needed for this patient. The code may then be assigned based on the severity of the patient’s complaint and the complexity of the aforementioned three key factors: history taking, examination, and level of medical decision-making. On the other hand, the neurosurgeon may choose to code by time when more than 50 percent of the total visit is spent on counseling and coordination of care for the patient. These two coding options are outlined in the “Evaluation and Management Services Guidelines” section of CPT 2000.

Coding for Time Counseled

For example, a patient is referred to the neurosurgeon for treatment of Parkinson’s disease (332.0) by implantation of deep brain stimulators. If the neurosurgeon met with the patient for 45 minutes, the visit could be coded as a 99243 (office consultation for a new or established patient, which requires a detailed history and examination and medical decision-making of low complexity) rather than a 99242 (office consultation for a new or established patient which requires an expanded problem focused history and examination, and straightforward medical decision-making), provided more than 50 percent of that time was spent in counseling. The neurosurgeon also would need to document what issues were discussed in counseling, such as possible treatments, additional testing, prognosis, etc.

Catherine G. Fischer, CPA, reimbursement policy advisor for the Marshfield Clinic, a 650-physician group regional healthcare system with more than 50 specialties in Marshfield, Wis., says, “Good medical recordkeeping requires that you document all the pertinent pieces of information. Just because you bill by time does not replace documenting history, exam and plan as appropriate. All pertinent medical information needs to be included in the note.”

Cobuzzi maintains that neurosurgeons must write down the precise start and stop times of their patient visits in their charts. Brink concurs, stating that the Health Care Financing Administration’s (HCFA)  guidelines require exact times and that physicians may run into difficulties if their files are reviewed by the agency and this information is not noted.

Coding for Established Patient Consultations

A patient is referred with a diagnosis of malignant neoplasm of the brain (191.x). In this case, the consultation typically might be coded 99244 (office consultation for a new or established patient requiring a comprehensive history and examination and medical decisionmaking of moderate complexity) whether counseling allows it to be coded by time (60 minutes spent on average with the patient) or by the  comprehensive level of the history and the exam and the moderate complexity of the medical decision-making.

If further treatment is initiated by the neurosurgeon, follow-up outpatient visits should be reported using office visit codes for established patients (99211-99215). In those visits, the neurosurgeon will need to document either two out of the three CPT-required E/M components (history, exam and medical decision-making) or that more than 50 percent of the time in the patient encounter was taken up with counseling or coordination of care. A follow-up visit to review findings for a brain tumor patient can require a great deal of time. Correctly document the begin and end time of the visit in the medical record along with a detailed statement of what was discussed during counseling, including but not limited to treatment options, diagnosis, and any questions from the patient and his family.

“With brain tumor patients, we encounter other E/M services that are dependent on the time spent in conference and counseling,” says Petruziello. “For example, our neurosurgeons meet with other specialists regarding each patient as part of a brain-tumor team,” she explains. “These services are coded as 99361 (medical conference by a physician with interdisciplinary team of health professionals
or representatives of community agencies to coordinate activities of patient care [patient not present]; approximately 30 minutes) or for additional time, 99362 medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care [patient not present]; approximately 60 minutes),” she advises. These codes can be used as an option when there is no face-to-face contact with the patient.

Coding Special Circumstance Counseling

Neurosurgeons may encounter other situations that require E/M services involving intensive counseling. “We have had cases in which the neurosurgeon spends significant time in conference with the family of a neurology intensive care unit (NICU) patient who is comatose (780.01), perhaps due to cerebral/vascular stroke (436), for example,” says Petruziello. For a telephone conference, this service would be coded 99373 (telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other healthcare professionals [e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists]; complex or lengthy [e.g., lengthy counseling session with anxious or distraught patient, detailed or prolonged discussion with family members regarding seriously ill patient, lengthy communication necessary to coordinate complex services of several different health professionals working on different aspects of the total patient care plan]). If this discussion is in person with the family, time spent can be included in the E/M time, as the guidelines specify time that the physician spends “face-to-face with the patient and/or family.”

“Be aware that these codes are not payable by all carriers,” cautions Petruziello. “You should check with the payer involved and follow their proscribed documentation procedures to get proper reimbursement.”

“Remember, time spent in counseling is a variable that can determine the entire level of E/M service for the physician,” states Fischer. Provided that time spent in counseling or coordination of care is the majority of the service, it well may override all other considerations. Neurosurgeons should note that they cannot count the time spent in taking the patient’s history or performing an examination as  counseling time. The physician must look at the entire patient encounter and decide if the majority of time was spent in counseling and coordination of care, or if the other three components should be the deciding factor when choosing an E/M level. But remember, the medical record must document the time spent.