EM Coding Alert

Question: Encounter notes indicate that the provider performed an office E/M service along with a neurobehavioral status examination to check the patient for a concussion. The neurobehavioral exam took 24 minutes and involved “?s on acquired knowledge, language, memory, problem solving, visual/spatial.” Can I report the E/M and the neuro exam separately?

Michigan Subscriber

Answer: In this instance, no. For this patient, you’ll only be able to report the E/M service.

Do this: Roll the work for the neuro status exam into the overall work for the E/M service. Then, choose the most accurate E/M code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) code range.

Explanation: Coding 96116 (Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour) along with the E/M is not only inaccurate in this scenario, it could also lead to problems down the line. Per National Correct Coding Initiative (NCCI) edits, 96116 is a column 2 code for E/M services. So, even though it is possible to bill for the status exam with a modifier when it is distinct from the E/M service, the code is bundled into the office E/M service your provider is performing.