Neurosurgery Coding Alert

You're fairly clear on prolonged services codes, but you'd like a little practice, right? Try coding the following case studies and then review the responses offered by our experts to test your coding skills.
 
Case #1: The neurosurgeon sees an elderly established patient who has been in an automobile accident and has spinal nerve damage. The surgeon provides an E/M service that - measured by the key components of history, examination and medical decision-making (MDM) - qualifies as a level-three outpatient visit (99213). The patient's ride is late, and he begins to show signs of fatigue and confusion. Over the next two hours the physician spends about 40 additional minutes monitoring the patient's status.
 
Coding #1: In this case, because the physician provided services beyond those typically included in a level-three established patient office visit (requiring 42 minutes longer than the 15-minute reference time for 99213), you may report 99213, 99354

Case #2: Following diagnostic tests revealing the presence of a brain tumor, a patient arrives for an outpatient consultation with the neurosurgeon. Based on the components of history, examination and MDM, the visit warrants a level-two consult visit (99242), but the physician spends an hour and a half discussing with the patient all the potential treatment options for his condition, including the risks and benefits of each. The total face-to-face time for the visit is 110 minutes.
 
Coding #2: Because the surgeon spent more than half of the encounter in counseling, you should report 99245 (Office consultation for a new or established patient ...) for the consultation plus 99354 for prolonged services. The reference time for 99245 is 80 minutes. If you subtract this from the total visit time of 110 minutes, you are left with 30 minutes (the minimum additional time to report prolonged services). For the first hour of prolonged services, claim 99354.

Case #3: A patient arrives for a consult concerning possible treatment with facet joint injections for back pain. The physician examines the patient and spends an additional 25 minutes discussing the merits of various treatments. Based on history, exam and MDM, the service qualifies as a level-two consult (99242). The total visit lasts 45 minutes.
 
Coding #3: In this example, the surgeon's face-to-face time with the patient does not meet the threshold for prolonged services. CPT lists a reference time of 30 minutes for 99242, leaving only an additional 15 minutes unaccounted for - not enough to report prolonged services.
 
But because counseling makes up more than 50 percent of this visit (25 of 45 minutes), you can choose an E/M level based on time alone. In this case, you should report code 99243 (Office consultation for a new or established patient ...), which has a reference time of 40 minutes).