Neurology & Pain Management Coding Alert

E/M level, testing codes, and Dx coding to seven characters are key.

Concussions are a real and serious medical condition for patients. The claims from concussion treatments can also be a figurative headache for coders. Assigning the correct codes for patient testing and for the eventual diagnosis can get confusing.

You’ll need to figure out which testing codes you might be able to report — and the ones you shouldn’t. Also, you need to keep an eye out for office evaluation and management (E/M) codes and report ICD-10 codes to maximum granularity to successfully code concussions.

So, take this advice and get the relief you need from concussion coding concerns.

Code for E/M, Testing

“Simple concussions usually require little intervention,” points out Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. The initial step in diagnosing a concussion likely be an office evaluation and management (E/M) service, which you’d report with a 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.) category, depending on encounter specifics. For a treatment plan, Falbo continues, the provider would probably recommend observation, symptom management, nonparticipation in activities that could aggravate the injury, and rest.

To assess the patient’s cognitive functions, your provider may well also administer an evaluation tool to determine the severity of the patient’s condition. This particular kind of test does not have a precise CPT^® code attached to it, but that shouldn›t send you scurrying for a code from the central nervous system assessment/tests section of CPT^®.

Coding 96116 (Neurobehavioral status exam ...), for example, 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 exam, the code is actually bundled into the office E/M service your provider is performing.

Instead, Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, recommends that if your provider administers a health hazard appraisal, such as the sport concussion assessment tool (SCAT) 2 or 3, you should use 96160 (Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument). Of course, you’ll have to choose an evaluation for the specific type of concussion the patient suffered.

Get Diagnoses Down Pat

The ICD-10 codes for concussion are, on the surface, easy to assign based on the patient’s history. You would choose S06.0X- (Concussion), adding a sixth digit, 0, if the patient did not lose consciousness during the incident; 1 if there was a loss of consciousness that was less than 30 minutes; or 9 if a loss of consciousness of an unspecified duration occurred.

The code, however, takes a seventh character that can muddy the waters for coders. If this is the patient’s first encounter for the condition, you would add the seventh digit, A, for the initial encounter. But Holle notes that, “if the patient is seen again in a week and now has no further symptoms of the concussion, … the seventh character will be a D for subsequent visit because the patient is in the healing phase and no longer under treatment.”