Neurosurgery Coding Alert

Coexisting conditions influence an E/M service's basic components (history, exam and medical decision-making, or MDM) which in turn may raise the encounter to a higher E/M service level. Because failure to document coexisting conditions can result in insufficient data to support the appropriate E/M code, physicians must strive to list all relevant diagnoses for the services reported if they want to receive the reimbursement to which they are entitled. New Complaint Affects History and MDM The type and severity of a patient's chief complaint influence the level of service provided. Similarly, the presence of pre- or coexisting conditions or other signs and symptoms may lead to increased risk to the patient, more (and more complex) data to be reviewed, the need for a more thorough examination, and a generally higher level of MDM, says Teresa Thompson, CPC, an independent coding and reimbursement specialist in Sequim, Wash. Coexisting conditions or new signs and symptoms may not be immediately apparent, and they often reveal themselves during the history portion of the E/M service. Or, the information may come from the patient's family or previous medical documentation. For example, an established patient with spinal injury (e.g., 722.10 , Displacement of lumbar intervertebral disc without myelopathy) arrives for a routine presurgical visit. During the visit, the patient complains that his low back pain has been worsening and that he also has pains in his neck (723.1) and elsewhere (e.g., 729.5, leg), as well as stiffness (724.8) and difficulty sitting and rising (719.7x). 

Upon further questioning, the surgeon discovers that the patient had fallen several days before while playing with his grandchildren. Concerned that the patient may have caused additional (or new) damage, the surgeon decides that an updated patient history and thorough examination are warranted. In this instance, a straightforward visit to discuss an upcoming surgery and recovery is transformed into a level-four (99214, Office or other outpatient visit for the evaluation and management of an established patient ...) or -five encounter. To establish medical necessity for such a comprehensive service, the physician must document the signs and symptoms (e.g., 723.1, 724.8, 719.7x, etc.) that led to the decision to perform the exam, says Cathy Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J. And the surgeon should note that there was a new patient complaint that prompted the exam. An established diagnosis of misplaced disk alone, for example, would not support such a high-level service. Note that the primary diagnosis code on any claim should describe the most important reason for the visit, while secondary diagnoses must be relevant to the visit that is being reported. In this example, the primary diagnosis [...]