Neurology & Pain Management Coding Alert

Evaluations between nurses and patients for routine follow-up visits or other minor services are common in neurology practices, but many subscribers have expressed concern about billing for a visit when the neurologist doesnt see the patient. Normally, the most accurate way to bill for a short nurse-only evaluation and management (E/M) visit is to use 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician).

The Typical Five-minute Nurses E/M

Typically, for a nurse-only visit, the presenting problems are minimal, and the normal visit time is five minutes, says Mary Mulholland, BSN, RN, CPC, reimbursement analyst in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. The time spent with the patient may vary with the needs of the patient. The nurse might render any range of services, including, but not limited to, vital sign checks, injection management, or review of self-medication administration, including a discussion of possible medication side effects.

Melody Mulaik, MSHS, CPC, president and co-founder of Coding Strategies Inc., a Dallas, Ga.-based consulting firm that supports more than 500 physicians nationwide, says, In a neurology practice, where patients with conditions such as seizure disorder (780.39) will come in for a Dilantin check to see if their medications need to be adjusted, the nurse will go over the results of the blood test with the patient. The nurse also would check vital signs and ask the patient if the seizures are under control.

Mulaik also says that nurse-only visits typically involve medication management and patient education. Injection management often is taught to patients with chronic migraines or multiple sclerosis who self-administer medication for their conditions. Many times, the nurses assist patients who have decreased mental status with medication management to ensure the appropriate doses are taken at the correct frequency.

When the Nurse Notices a Change in Condition

Mulholland says that the 99211 shouldnt extend too far beyond the suggested five minutes. There are no prolonged service codes or modifiers for extra time for the 99211 because anything that takes much longer than the normal five minutes is more complex than a registered nurse should be performing.

If, for example, a migraine headache (346.90) patient meets with the nurse to discuss how she is handling a new pain medication, but during the course of the visit, the nurse discovers that the patients blood pressure has risen dramatically, the nurse should bring in the neurologist. When the nurse, in the course of evaluating the patient, discovers an abnormality, a new problem or an exacerbation of an existing problem, he or she must notify the supervising neurologist, says Mulholland. Its not within the nurses scope of practice to prescribe a medication or give the patient an injection that hasnt been ordered by the neurologist.

Once the nurse alerts the neurologist to the patients new symptoms, the neurologist most likely would want to see the patient right away. If the neurologist subsequently provides an E/M service for this patient on the same date of service, only the neurologists service would be reported, says Mulholland. The claim form must contain the medical necessity for the neurologists services as demonstrated by the use of the appropriate ICD-9 diagnosis. No modifiers are necessary, as the ICD-9 codes will identify the conditions treated during the visit.

For example, the neurologist would report the visit with the migraine headache patient described above by using an established patient E/M code (99212-99215) with the diagnosis codes for migraine headache (346.90) and high blood pressure (796.2, elevated blood pressure reading without diagnosis of hypertension). The 99211 would not be billed.

Incident to Guidelines Apply

Nurses who bill 99211 need to follow the incident to guidelines set forth by the patients insurance carrier. Medicare specifies that practices billing incident to must meet its requirements, which state that the neurologist must be on-site at the time of treatment, have originally seen the patient for the first visit to the office or clinic, and seen the practices established patients for any new medical problems.

When billing the 99211, the nurse should document the date of the visit, a brief description of the reason for the visit, and the services provided, says Mulholland. The name of the supervising neurologist also needs to be identified in the notes. Something like, April 5, patient came in for blood pressure check to ensure shes doing okay on her new pain medication. Performed review of systems; no adverse effects found. Dr. Jones on-site. This should be signed by the nurse. That way, if an auditor ever came in, they would know that the neurologist was available to the nurse. In the absence of the declaration about the doctor being on-site, the neurologists signature and date (and comments, as appropriate) could also justify the neurologists supervision of the service.

Of course, the guidelines for billing 99211 apply to all services that may not require the presence of a neurologist, which include evaluations performed by physician assistants (PA) and nurse practitioners, who also may bill incident to the physicians services. The difference between a PA or nurse practitioner and a registered nurse (RN) is that PAs and nurse practitioners have their own billing numbers and therefore use the same guidelines as a neurologist, says Mulholland. RNs are not billing independently, so they have their own rules. The services the RN provides will depend on his or her scope of practice and will vary on a state-by-state basis. Therefore, PAs or nurse practitioners can bill either using their own billing numbers or incident to the physicians services using the neurologists billing number.

The Proper Use of 99211 and Audit Warning Melody Mulaik, MSHS, CPC, president and co-founder of Coding Strategies Inc., a Dallas, Ga.-based consulting firm that supports more than 500 physicians nationwide, provides the following insights on 99211: The Health Care Financing Administration (HCFA) reports that evaluation and management (E/M) prepayment audits reveal a number of errors regarding the coding of 99211 visits. An independent report indicates that nationwide, 99211 is one of the most abused codes for Medicare and other health plan claims. Documentation for 99211 should include a minimum of: date of service; vital signs (if taken); the service provided to the patient (in addition to injections, venipuncture, etc.); and the signature of the nurse or other practitioner. The nurse or other practitioner must have face-to-face contact with the patient. The following are examples of when not to use CPT code 99211: Neurologist gives patient orders over the telephone. Neurologist calls in prescription refill to the pharmacy. Staff calls patient to reschedule a procedure or appointment. Staff faxes medical records to a hospital. Staff records lab results in a patients chart and/or calls to inform patient of lab results. HCFAs focus when auditing this service is the medical necessity for a visit in addition to any procedure performed on the same date of service. For example, if a patient presents for a blood pressure check and to report on how she is doing with her medications, 99211 is the appropriate CPT code to report this service. There must be a neurologists order that the patient return to the office for a blood pressure check and to report on the effects of her medications, which establishes the patient diagnosis and medical necessity of the service.