Neurology & Pain Management Coding Alert

Eliminate payer guesswork with clear documentation If you've ever filed a claim using an "unlisted-procedure" code, you know how much effort is involved. To ensure that your neurologist gets reimbursed for procedures without specific codes, our experts offer the following three pointers. Tip 1: Describe the Procedure in Plain English Anytime you file a claim using an unlisted-procedure code (for example, 64999, Unlisted procedure, nervous system; or 95999, Unlisted neurological or neuromuscular diagnostic procedure) you'll need to include a separate report that explains, in simple, straightforward language, exactly what the neurologist did.
 
Insurers consider claims for unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. "Unfortunately, claims reviewers, especially at lower levels, do not have a high level of medical knowledge, and physicians don't always dictate the most accessible notes," he says. Part of the coder's job in preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman's terms.
 
"If the person making the payment decision can't understand what the physician did, there's not much chance that the reimbursement you receive will properly reflect the effort involved," says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Brick, N.J. Be careful to avoid or explain medical jargon and difficult terminology. And, if appropriate, you may even include diagrams or photographs to better help the insurer understand the procedure.
 
For example, CPT includes no specific code to describe electrosleep therapy, so  you should report the procedure using 95999. When describing the therapy, you should use the neurologist's operative notes as a guide, stressing the main points of the procedure. You may report, for instance, that "using electrodes placed externally on the patients head, the physician administered short-duration, low-amplitude pulses of direct current to the patient's brain" and include details such as "to treat chronic insomnia that has not responded to other treatments" to reinforce medical necessity.
 
"A little extra effort to write a clear description of the procedure can go a long way toward improving your reimbursement," Cobuzzi says. Tip 2: Compare the Procedure to an Existing Code An insurer will decide to pay an unlisted-procedure claim by reading your description of the procedure and comparing it to a similar, listed procedure with an established reimbursement value, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. Rather than leave it [...]