Eli's Rehab Report

Physical medicine and rehabilitation practices that frequently perform mini-mental status examinations (MMSEs) on patients suffering from strokes, mini-strokes, ALS or other conditions that effect the brain should keep in mind that MMSEs are not separately reimbursable by Medicare. These examinations should never be billed using 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). MMSEs should always be included as part of the E/M service to avoid improper billing.

There is no code for MMSE, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services Inc., a medical billing and healthcare consulting firm in Broomfield, Colo. Many practices will ask how to code this and say that they cant find the descriptor in CPT, but these assessments are not separately billable. They should be included as part of a patients E/M service.

Do Not Use 96115

Some physiatrists believe that the time and skill spent performing MMSEs should not go unpaid, so they erroneously bill using the neurobehavioral status exam, which is a more comprehensive exam, normally performed by neurologists and psychologists. Patricia Caldwell, who bills for one physiatrist and a neurologist at Canyon Spine and Neuro in Denver, says she was erroneously advised to bill 96115, and that the code worked well for a while. We knew there was no code specifically set aside for MMSEs, so we called a neurology practice nearby, and they told us to use 96115. Its possible that they didnt understand that we werent performing the comprehensive exam, so they told us the wrong code. But, we billed it four or five times before we realized it was wrong, and Medicare paid us for it each time.

Caldwell says the physiatrist caught the mistake after noting that the code descriptor mentioned an interpretation and report and that it was billed per hour, which was not even close to the short question-and-answer session he had performed with the patients. Caldwell called the insurer immediately to try to correct the situation after the error had been found. What we learned was that the statement was right in our LMRP it said that 96115 could not be used to evaluate patients who were anxious or confused before they entered a nursing home, and thats what we were using it for most of the time. In addition, the LMRP stated that the Folstein mini-mental exam (or similar test) is not separately reimbursable by Medicare because it is included in the clinical interview portion of an E/M service.

The fact that Caldwell was being reimbursed for her 96115 bills is not uncommon, says Page. Its 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 but that would not be the case with claims for MMSEs, Page says. Many insurers dont review documentation before they process claims, so they pay for what they believe to be reimbursable services. However, if these codes are inappropriately assigned and the practice is audited, all of the reimbursement would have to be paid back to the insurer, says Page. If the practice knowingly committed fraud by billing 96115 when they knew they werent supposed to do so for an MMSE, they would also be subject to fraud and abuse penalties by the OIG.

I would advise all practices out there who realize theyre billing MMSEs incorrectly to contact their insurer and find out how to correct the situation, Caldwell says. We refunded Medicare for what we owed them, and we know better than to bill that way again.

Billing MMSEs As Part of E/M

A 56-year-old patient with multiple sclerosis presents to the physiatrist stating that she has had trouble remembering things recently, and is concerned that her condition has worsened. The physiatrist asks the patient a series of questions, such as the patients address, her childrens names, how many states are in the United States, etc. The patient answers about 90 percent of the questions correctly. The physiatrist completes the visit by performing a full evaluation of the patient. During the E/M service, the physiatrist learns that the patient has been entertaining guests for two weeks, and suggests that the stress and extra work have contributed to her condition. He bills for the visit using 99214, with the ICD-9 codes for multiple sclerosis (340) and stress (308.0).

When an MMSE is performed, the level of E/M service is based on the complete documentation; it is not appropriate simply to add a level to the service just to demonstrate that something more than a typical E/M took place. The performance of a mini-mental exam should be factored in when the appropriate level of service is determined, Page says, but its not always correct to use time as the contributing factor for determining the E/M level. Instead, 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.

If, after the exam is complete, the patient asks the physician to determine treatment options, that time may count toward counseling and, if it comprises more than 50 percent of the visit, could allow the level of the visit to be based on time guidelines. For example, if a 78-year-old woman presents to the physiatrist for an exam prior to being admitted to a nursing home, the physiatrist may do an MMSE to determine how coherent the patient is and whether she is aware of what is happening. In many instances, the physiatrist would then discuss the patients prognosis with the patients family, if they are present, who normally ask a series of questions about the transfer to the nursing home.

If the examination took 15 minutes and the discussion with the family took 25 minutes, the level of service could be based on time. In this case, the time amounts to 40 minutes, which would warrant billing a 99215. However, when this higher level of service is billed to compensate for time spent, the physiatrist should maintain carefully documented notes regarding the amount of time spent in the exam, what occurred, and the amount of time spent with the family members, who was present, and what was discussed.