Neurosurgery Coding Alert

You can ensure that your neurosurgeon gets paid for E/M services and minor surgical procedures performed in a teaching setting -- if you know the documentation and supervision requirements for Medicare's teaching physician rules.

When your neurosurgeon works as a "teaching physician" (TP) and supervises a resident's services in a clinic or hospital setting, you will have to report your physician's work using the teaching physician rules, according to the Medicare Claims Processing Manual (MCPM), Chapter 12, Section 100.

The MCPM defines a resident as an intern or fellow who's enrolled in an accredited graduate medical education (GME) program.

Experts offer four field-tested strategies for reporting E/M services and minor surgical procedures using the teaching physician rules.

Let's say the TP provides an E/M service such as an office visit (99201-99205; 99211-99215) or an outpatient consultation (99241-99245) without the resident present. The TP may be able to use some of the resident's work under TP guidelines, says Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M.

How? "If the resident also performed the E/M service the TP performed, your neurosurgeon would have to duplicate the -critical and key portions- of the resident's services to bill under this guideline," Witt says. The TP should define -- and be able to defend -- those critical and key portions, she adds.

Example: Let's say a resident sees a new patient who wants a second opinion regarding a proposed spinal condition treatment. The resident conducts an expanded problem-focused history and exam. All of this is documented in the resident's progress note. The TP also evaluates the patient, performs an exam, and consults with the patient on his condition.

You should report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision making).

Tip: Don't forget to attach modifier GC (This service has been performed in part by a resident under the direction of a teaching physician) to 99202 to ensure that your Medicare carrier knows that you are reporting a service under the teaching physician rules.

"The TP doesn't have to duplicate the resident's progress notes," Witt says. The TP's note can refer to the resident's notes and state that the TP reviewed the resident's medical documentation and agrees with the diagnosis.

If the resident did not perform an independent patient evaluation, or did not perform the patient evaluation in conjunction with the TP, the TP must perform, document, and bill the office visit as he or she would in a non-teaching setting, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.
In other words, to support a 99202 claim, the neurosurgeon would have to document an expanded problem-focused history, an expanded problem-focused exam, and straightforward medical decision making, coding experts say.

Documentation requirements for the claims are steep, but a neurosurgeon can also code when he and the resident perform critical care jointly.
Example: Let's say the neurosurgeon and the resident treat a carpel tunnel syndrome patient who experiences anaphylactic shock due to an allergic reaction. They spend a total of 56 minutes of critical care time on the patient.

In this case, your physician may be able to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), as long as the documentation supports the code.

Key questions: When filing TP claims involving critical care, make sure the supporting documentation points out that the TP (the neurosurgeon):

- treated the patient jointly with the resident.

- directly supervised the resident for the full 56 minutes of treatment

- directly managed the patient's care

- referenced the resident's note in the documentation.

- supervised the resident during the visit's history and exam

- noted a discussion with the resident concerning the blood removal, patient stabilization and patient consultation.

When you report minor surgeries and endoscopic procedures, you should make sure the neurosurgeon documents that he or she directly supervised the entire procedure. That means the physician must be present in the room. For example, your neurosurgeon can't view the session through a monitor in another room, Pohlig says.

Suppose your neurosurgeon supervises the fellow during a skull-based surgery using the craniofacial approach. Report 61580 (Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, ethmoidectomy, sphenoidectomy, without maxillectomy or orbital exenteration) with modifier GC to show that the TP was in attendance, though he didn't perform the procedure. (Make sure the documentation shows that the TP directly supervised the entire procedure.)