Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon treated a new patient with multiple sclerosis (MS) of the brain stem. First, they performed an office evaluation and management (E/M) service that included high-level medical decision making (MDM). Then, they performed a magnetic resonance imaging (MRI) of the brain without contrast materials followed by contrast materials. The surgeon does not own the MRI equipment. How should I code this encounter?

Nebraska Subscriber  

Answer: For this claim, you should report:

• 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99205 to show it was significant and separately identifiable from the MRI
• 70553 (Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences) for the MRI
• Modifier 26 (Professional component) appended to 70553 to show that you are only coding for the interpretation and report of the MRI (Remember the reporting the professional service of imaging interpretation requires credentialing of the physician to perform and report this service.)
• G35 (Multiple sclerosis) appended to 99205 and 70553 to represent the patient’s MS

Alternate terms alert: Though G35 might appear to be a vague code for such a specific form of MS (MS of brain stem), the truth is it’s the only code for MS. Other terms you might see that you’d diagnose with G35 include:

• Disseminated multiple sclerosis
• Generalized multiple sclerosis
• Multiple sclerosis NOS
• Multiple sclerosis of cord.