Neurology & Pain Management Coding Alert

Get acquainted with your carrier's LCDs

You can't always count on CPT guidelines to tell you how to code for the numerous payers you deal with every day. These surefire tips will keep you organized so you can choose the right neuro code and modifier every time.

Scenario: Your neurologist injects 75 units of Botox around the forehead and scalp to treat migraines. You-ll report 75 units of J0585 (Botulinum toxin type A, per unit). If your neurologist doesn't use the remaining 25 units for another patient, you may claim them as waste by placing the excess amount in box 19 of the claim form. However, your payers differ as to how they want you to report waste units. For example, TrailBlazer requires that you append modifier JW (Drug amount discarded/not administered to any patient) to the supply code when reporting wasted drugs.

Don't just try-and-fail when reporting waste units in this situation. Here's how to keep straight who wants what every time:

1. Chart Those Choices

Best bet: Set up a spreadsheet to keep track of frequently applicable payer policies and quirky filing requirements (such as how to report wasted units). In this spreadsheet, you should also note which codes  each payer accepts for common procedures, which codes they never accept, which diagnosis codes they allow for each procedure code, which modifiers the payer allows, and how you should report them. Keeping a spreadsheet means that you-ve already ironed out who wants what.

-We have a notebook divided by payer with specifics for each. We use this information for discussions with providers,- says Nancy Lynn Reading, RN, BS, CPC, a coding educator with University Medical Billing at the University of Utah in Draper.

Example: Along the same lines as the example of the wasted Botox units, you may have one payer that wants you to place -2- in the units box if you use modifier 50 (Bilateral procedure) and another who  asks you to place -1- in the units box for that modifier, and you should make sure this information is at hand in your spreadsheet.

2. Don't Let Your Guard Down

To stay current on your payers- policies, you have to dig through their newsletters and Web sites. Because CMS has made a point of going paperless, you have to be doubly vigilant in checking for Medicare and Medicaid online bulletins.

Good practice: -We keep our private-payer manuals current with mailings we get and circulate all of this information to the staff in the office,- says Marianne Wink-Sturgeon, RHIT, CPC, ACS-EM, coder for the department of neurology at the University of Rochester Medical Center in New York.

What to do: If your patient is covered by TrailBlazer Health in Texas, and you go to this Medicare carrier's Web site (www.trailblazerhealth.com), in the center of the page you-ll see a -What's New- column to help you keep up with the latest information.
If you have a question about a specific policy, click on -Texas- under -Part B- on the left side of the screen. Then to find a policy for a particular procedure, click on -LCD (Local Coverage Determination)- in the left-hand column. You can search by the name of the procedure or the CPT code.

Example: You have a report of a patient with documented acute infective polyneuritis, and the neurologist wants to perform a motor nerve conduction test. You want to make sure the TrailBlazer policy says the diagnosis code proves medical necessity for this diagnostic service. You know the procedure code is 95900 (Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study).

1. Type 95900 into the search field on the TrailBlazer Web page. This will bring up links to the LCDs for this code. In this case, there is only one, and when you click on that link you-ll see the LCD, -Nerve Conduction Studies.-

 2. Scroll down past the explanation of the procedures, and you-ll see lists of exactly which CPT codes you may use to report this service (which includes 95900) and lists of which diagnosis codes prove medical necessity. Code 357.0 (Acute infective polyneuritis) is on the list, so you can trust that you are reporting a code combination that TrailBlazer will pay.

3. Analyze Denials and Payments for Clues

You can seize many benefits by taking the time to clarify and summarize payer policies. Analyze payments and investigate those that appear too low before they add up too much, experts say.

You-ll thrive over time if you-re willing to learn from your denials. If a payer consistently denies a specific code, you should thoroughly investigate it, identify what triggered the denial, and implement corrective actions to prevent it. Don't automatically appeal or write off every denial, Reading says: -You need to determine if you coded properly and had the correct documentation up-front and then determine if the denial has merit.-

4. Network, Network, Network

For many coders, listservs are a lifesaver. -We also keep current by subscribing to the listserv associated with our government payers,- Wink-Sturgeon says. Listservs are great tools that give you the chance to get answers from others in your specialty and experts in the field.

Bonus: Look for the specialty lists offered by The Coding Institute at www.coding911.com. You can sign up for our neurology discussion group there, and access the questions and answers from past discussions.

When you have a question about a payer's policy, you can post your query to the list to hear from others who have dealt with the same situation.

If another coder provides you with official documentation to solve your problem, you-ve saved yourself about 45 minutes of waiting for your payer's customer service to take your call. And even if you don't get an official answer, you-re now armed with information to help you decide if the payer representative who answers your call is giving you an answer you can trust.