Neurology & Pain Management Coding Alert

Remember to move away from late effects codes.

If you're scratching your head when it comes to coding head injuries, you're not alone, especially when managing concussion reporting. The solution? Examine what services the physician provided and you'll make your way closer to the best possible code.

1. Evaluate Procedure Code Choices

As with any procedure, focus first on the appropriate CPT® code to describe your provider's service. You have several options, depending on how comprehensive the service was.

In many cases, your physician will provide an outpatient E/M service to evaluate the concussion. Report the appropriate code from the 99201-99215 (Office or other outpatient visit ...) series.

If you administered a computerized neuropsychological test to determine the impact of the concussion, report 96120 (Neuropsychological testing [e.g., Wisconsin Card Sorting Test], administered by a computer, with qualified health care professional interpretation and report).

If, however, your physician administered a non-computerized neuropsychological test, the correct code instead is 96118 (Neuropsychological testing [e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test], per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report).

Sometimes your physician might perform both the neuropsychiatry testing and the E/M service at the same session. Code 96118 is bundled into the E/M service according to CCI edits, but you might be able to report both codes, assuming that your documentation can demonstrate the separate nature of the two services. You would append a modifier to the neuropsychological testing code – two possibilities include modifier 59 (Distinct procedural service) and modifier XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service).

Concussion patients often will return to your office for follow-up visits. Submit the applicable E/M code for each of these visits, unless the physician performs a different service besides an E/M. For instance, if he saw the patient shortly after the concussion and the patient's only symptom was blurred vision, the doctor might want to administer a vision test after two weeks pass. If the vision test is the only reason for the visit, you'll report the appropriate code for that service instead of an E/M code.

2. Sort Out Minor Vs. Serious Injuries

If your neurologist is called in to see a patient with a head injury, verify what's involved with coding these events from a diagnosis standpoint.

Minor injuries: If the patient has a contusion of the head, remember that a contusion, by definition, includes a bruising injury that does not break the skin. You'll report a diagnosis based on the contusion's location, such as S00.03- (Contusion of scalp) or S00.33- (Contusion of nose). If the physician does not specify a particular location on the patient's head, you'll report S00.93- (Contusion of unspecified part of head).

Important: Each of the codes related to contusion expands to specify the type of encounter, so be sure to include "A," "D," or "S" as the seventh character. For example, the code for an initial encounter (active treatment) for a scalp contusion is S00.03XA.

Significant injuries: The patient might have other, more significant injuries involving the head, such as such as concussions, cerebral lacerations, cerebral contusions, and open wounds. ICD-10 includes numerous codes for head injuries, which allows you to report these as accurately as possible. Begin by looking at code families such as S06.0- (Concussion) or S06.3- (Focal traumatic brain injury) for cerebral laceration or hemorrhage.

3. Move From 'Late Effects' to Seventh Character

During all those years you coded with ICD-9, you could turn to "late effects" codes to describe the residual effect (condition produced) after the acute phase of an illness or injury has ended. Using a "late effects" code helped create the causality relationship between a prior injury and the current condition your provider was treating.

"This could be helpful for the patient and insurer to track additional tests and treatment related to the initial injury," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. "It was also important to differentiate the late effects of one injury from a subsequent new acute injury, should one occur."

Now, with ICD-10, you indicate sequelae with "S" as the code's seventh character. ICD-10 guidelines state that "S" represents complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. "When using seventh character 'S,' it is necessary to use both the injury code that precipitated and the code for the sequelae itself.," the guidelines state. "The 'S' code is only added to the injury code, not the sequelae code. The seventh character 'S' identifies the injury responsible for the sequelae. The specific type of sequelae (e.g., scar) is sequenced first, followed by the injury code."

An example for a concussion could be: F07.81 (Postconcussional syndrome) or G44.3- (Post-traumatic headache...), then S06.0X-S (Concussion..., sequelae) with the sixth character indicating the duration of loss of consciousness.