Neurosurgery Coding Alert

Are you making the mistake of reporting 96115 for so-called "mini"-mental status exams (MMSEs)? If so, you're opening yourself up to potential fraud charges. The mental status exam (MSE) described by 96115 is an extensive procedure, while an MMSE is incidental to any E/M services the neurosurgeon provides.

When in Doubt, Consider the 'Time Factor'

Perhaps the easiest way to distinguish an MSE from a "mini" MSE is to consider the time the physician spent providing the service. The MMSE is a 30-element examination, originally created to provide a quick and simple summary test, according to CPT Assistant , Volume 10, Issue 10 (October 2000). In general, the MMSE takes less than 15 minutes to perform and interpret. "It was never meant to substitute for more comprehensive testing," CPT Assistant states.
 
Physicians administer the exam - which can be a valuable diagnostic tool for stroke victims, Parkinson's patients and others - to test a patient's mental acumen and awareness. "The doctor will test the patient's deductive reasoning skills, ask general questions such as the current date, and have the patient perform some basic math computations," says Helen Wilson, CPC, medical coder and primary-care physician liaison for Cochise Health Alliance, a 31-physician multispecialty medical group in Sierra Vista, Ariz. Also, physicians may use a slightly longer standardized testing tool, which takes up to 30 minutes to perform and interpret.
 
In contrast to an MMSE, an MSE described by 96115 (Neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning] with interpretation and report, per hour) involves a lengthy neurobehavioral status examination lasting about one hour. This would include a much more detailed evaluation of the patient's thinking, reasoning and judgment than the comparatively superficial MMSE provides, according to CPT Assistant. In particular, MSE might include a full evaluation of digit span, a four-item similarities task, a 15-item naming task, a 10-word learning test with recall and recognition, four drawing items, and a word-list generation task, as well as other tests.

Include MMSE in E/M Services
 
 Coders searching for a CPT code for MMSE will do so in vain. "The code doesn't exist," says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems Inc., which supports family practice physicians in Broomfield, Colo. Rather, if documentation describes only a cursory exam of 30 minutes or less, Medicare considers the MMSE testing to be part of any associated consultation, clinical interview or E/M service and will not pay it as a separate, reimbursable service, she says.
 
Although you may consider the MMSE when selecting an E/M code, the test does not automatically raise the E/M service level. E/M levels must be chosen according to the three components of exam, history and medical decision-making. Only report a higher-level E/M service if the MMSE contributes significantly to these components. Specifically, Page sees MMSEs as part of the physical-exam section of the E/M. "Instead of examining the 'physical' body, the provider is examining the 'mental' status of the patient," she says.
 
Alternatively, if counseling and coordination of care consume more than 50 percent of the visit, you may use time as the determining factor when assigning an E/M service level. For instance, if, after undergoing an MMSE, a new patient discusses his condition with the physician for 35 minutes of a one-hour visit, you may code 99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) based on time alone. When reporting E/M services based on time, maintain careful documentation outlining the time spent face-to-face in counseling or coordinating care with the patient or his family.

Don't Continue Improper Coding

Page strongly advises against reporting 96115 for an MMSE, even if insurers have reimbursed in the past. "It's true that some payers will pay claims like this, but that often occurs because the payers assume that the codes submitted represent the work performed. That is not the case here," she says. Many insurers don't review documentation before they process claims, so they pay for what they believe to be reimbursable services. "If these codes are inappropriately assigned and the practice is audited, all of the reimbursement would have to be refunded," Page says. If you knowingly commit fraud by billing 96115 for an MMSE, you could be subject to fraud and abuse penalties by the U.S. Office of Inspector General (OIG).
 
Contact your insurers immediately if you have been billing MMSEs incorrectly. If you come forth, the insurer will work with you to correct the problem. You will have to return some payment, but it's better than the alternative.

Use Your Documentation to Support 96115

If the physician performs a true neurobehavioral exam as described by 96115, he or she must document the test in full, noting the additional time spent above and beyond that involved in any accompanying E/M service. Documentation is especially important because 96115 is a time-based code. Presumably, a physician could spend two to three hours performing a complete mental status exam. In this situation, you could appropriately report multiple units of 96115. Without proper documentation, however, the claim would stand little chance of prompting reimbursement.
 
Most often, the physician will provide a mental status exam with an E/M service, such as an office visit or consult. To ensure reimbursement for both services, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.
 
To support medical necessity for the mental status exam, report all relevant signs and symptoms, such as delirium (290.41), dizziness (780.4), slurred speech (784.5) or others, as well as any potentially relevant existing diagnoses, such as stroke (436) or Parkinson's (332.0), Page says. The diagnoses linked to the E/M service may be the same as or different from those linked to the exam, depending on the circumstances. For example, if the specific symptoms prompting the E/M lead to the decision to perform the exam, you may report the same diagnoses for each. If an elderly diabetic patient presents for neuropathy but also has symptoms that prompt the mental status exam, link the diabetes/neuropathy diagnoses to the E/M service and separately list the relevant signs and symptoms to justify 96115.