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.

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 prior to discovery of new signs and symptoms was 722.10. Following discovery of the new signs and symptoms, the neck pain, stiffness and other difficulties provide the primary justification for the in-depth service provided and as such should be listed as primary diagnoses. Because the previously established spinal injury remains relevant, however, 722.10 should be included as a secondary diagnosis.

Patients with a pre-existing condition seeking treatment for a new but already-identified problem may also need special attention. For example, a patient with high blood pressure has postlaminectomy syndrome (722.8x), which the surgeon may wish to treat initially with an anti-inflammatory or other medication. Before making such a decision, the surgeon must consider any possible interactions new drugs may have with the patient's hypertension medication. This adds a degree of medical-decision making and therefore could raise the level of E/M. In this case, the postlaminectomy syndrome is the primary diagnosis, while hypertension (e.g., 401.x) may be listed as a secondary diagnosis because it is relevant to the patient's medical management.

Similarly, other pre- or coexisting conditions, such as insulin-dependent diabetes (250.01), congestive heart failure (428.0) and respiratory or cardiovascular problems, may affect E/M levels. In all cases, proper documentation (i.e., a complete record of the pre-existing condition) is required to substantiate a higher-level E/M service. But if the pre-existing condition does not affect medical management during a given service, you should not include it as a secondary diagnosis. For example, a patient scheduled for removal of brain neoplasm may have a preexisting allergy condition (e.g., 493.9x), but the condition would not affect treatment for the neoplasm and therefore should not be listed as a secondary diagnosis.