Neurosurgery Coding Alert

Its common for neurosurgeons to see patients in the emergency room (ER) and subsequently admit them as inpatients. The ER visits that precede hospitalizations can be extensive, even hours long. In general, however, a neurosurgeon will be reimbursed only for either the ER visit or hospital admission, if they both occur on the same day.

You cant bill for two evaluation and management (E/M) codes on the same day. Most carriers will only pay for one, so most practices choose the code that has the higher reimbursement. Thats usually the inpatient history and physical, explains Barry Haitoff, president of Medical Management Corporation of America, a billing and management firm in Brewster, N.Y.

According to CPT 2000, the initial hospital care codes (99221-99223) include any care provided elsewhere on that date: When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital, physicians office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

It is appropriate, however, to consider the work done in the emergency room when determining which level code to use for the admission. As CPT 2000 states, The inpatient care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of services as well as in the inpatient setting.

There is usually overlap between the ER examination and the examination, history and decision-making associated with the inpatient admission. When a neurosurgeon goes to the ER, much of the work done there ties into what they need for the hospital admission, says Gail Levy, a consultant with ADB Associates, a healthcare reimbursement consulting firm based in Baltimore.

Knowing Which Inpatient Codes to Use

Which of the three hospital care codes 99221, 99222 or 99223 is appropriate, then? (See Inpatient Hospital Care Codes, page 47.)

Medical decision-making is what drives the difference between the hospital care codes, because even the lowest-level code requires a detailed or comprehensive history and examination, explains Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based coding and reimbursement firm.

The three elements of medical decision-making include:

1. Mortality and morbidity. What are the risks of significant complications, death, or comorbidities associated with the patients presenting problems, diagnostic procedures and/or possible management options?

2. Diagnosis and management options considered. Has a definitive diagnosis been established, or are there differential diagnoses? Will further studies or consultations be performed?

3. Records and tests reviewed. How many and how complex were the tests and medical records that had to be reviewed and analyzed?

To use 99223, the highest inpatient care code, two of the three above criteria for medical decision-making must be complex. Rhonda Petruziello, CPC, reimbursement specialist for neurosurgery at Cleveland Clinic Foundation in Cleveland, gives the follows example of a 99223: A 10-year-old boy is hit in the head with a bat during a baseball game. He is unconscious but then he comes around and seems fine. He is taken to the hospital as a precautionary measure and scans are taken, but again, nothing seems to be wrong. Then he begins to slur his speech and he is admitted to the hospital. By that evening, the neurosurgeon has to perform surgery to aspirate a subdural hematoma (853.02).

Still, a neurosurgeon may want a return on the considerable time invested between the ER visit and hospital admission. Its not wrong to take into account the time spent, but CPT includes a disclaimer that the time periods associated with E/M codes are only averages. If you use time as the level determinant, then over 50 percent of your time must be spent counseling and coordinating care face-to-face with the patient and/or family, Parman advises.

The Problem With Same-day ER and Inpatient Claims

Some neurosurgeons ask, Why not go ahead and file a claim for the E/R visit to report that activity, even though it wont be reimbursed?

Medicare frowns on it. They see billing things that you know are not covered as an abusive practice, and they have started sending out cease-and-desist letters that say, Its costing us money to deal with you, Parman explains.

Levy agrees. If the carrier has made it clear that they dont want you to do it and you do, it could put you in the situation of abusive billing. Most wont pay for more than one E/M service for one day, so if you separately bill for the ER visit and admission its almost unbundling because of the standard practice in the industry, she says.

Use Prolonged Services and Consult Codes

One approach to billing for a three-hour-long ER visit followed by an admission would be to use 99223 in conjunction with the extended inpatient service codes, 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour), and 99357 (each additional 30 minutes). However, even after subtracting the ER-specific activities from the overall time, you might still face review from the carrier, advises Mary Hensley, administrator of the department of neurology at the University of Iowa in Iowa City.

Those prolonged service codes are generally subject to review, so you would have to have very clear documentation. Sequencing of the codes might also be an issue, Hensley adds.

Another approach is to use 99223 along with the codes for prolonged physician service without direct (face-to-face) patient contact; 99358 (prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; first hour), and 99359 (each additional 30 minutes). These codes can be used in the in- or outpatient setting, and before or after face-to-face time with the patient, so the sequencing is not an issue, Hensley explains.

Petruziello gives this example of a 99358: A neurosurgeon sees a malignant brain tumor (191.0-191.9) patient in the clinic. The patients family wishes to consult with the neurosurgeon following the appointment because they are unsure of the patient responses and the information he provided to the family. Due to the lengthy amount of time spent in consultation with the family, backed up by a great deal of documentation (including a detailed notation of time) in the patients medical record, 99358 is charged in addition to the regular initial inpatient visit.

If the patient is not admitted, then the ER visit codes (99281-99285) or consultation codes (99241-99245) might be used.

Inpatient Hospital Care Codes 99221 Initial hospital care, per day, for the evaluation and management of a patient which requires a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision-making that is straightforward or of low complexity. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patients hospital floor or unit. 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patients hospital floor or unit. 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patients hospital floor or unit.