Neurology & Pain Management Coding Alert

Before 1997, neurologists had to rely on general multisystem examination guidelines as prescribed by Medicare, which took several factors into account that were not specific to neurologists, including eyes, ears, nose, throat, cardiovascular, respiratory, and others. In 1997, the Health Care Financing Administration (HCFA) released the single-system examination guidelines for several specialties including neurology. But the initial design of the single system exam for neurologists did not take the child neurologist into consideration, according to Bruce H. Cohen, MD, chief of the Section of Pediatric Neurology and co-director of the Brain Tumor Center, which has more than 40 neurologists at the Cleveland Clinic Foundation in Cleveland, Ohio.

Examination details that add time to the standard pediatric neurological evaluation, such as neonatal reflexes and head circumference, were not included in the single system examination guidelines, Cohen explains. Yet performing and documenting the results of language repetition, a test that cannot be performed with an infant, is not only included, but also required.

Some third-party payers follow Medicare guidelines and maintain that if you cant do a memory and language test, you cant bill a level four initial examination (99204) or higher, Cohen says. These payers fail or refuse to recognize that only a small percentage of pediatric patients receive Medicare benefits for disabilities.

Substituting Items of Work

Richard A. Roski, MD, FACS, American Medical Association (AMA) CPT advisor for the American Association of Neurological Surgeons, says that the key to reimbursement may be in substituting items of work. While a pediatric neurologist will not be able to gain memory test results from an infant, there is the startle reflex check and other additional tests that can be clearly identified in the neurologists documentation, reports Roski, founder of Quad City Neurosurgical Associates, a medical practice specializing in the surgical treatment of the central nervous system. Adding these items of work to the examination documentation and submitting that documentation can help a neurologist to prove that he or she performed a comprehensive examination.

Addressing all the points raised in the single system examination is still important, even if it is to indicate that no results could be gained. When you do a neurological examination on a child, you have to comment, I tried to do cognitive testing, but it was not possible because of the patients age, Roski says. He adds, The evaluation and management (E/M) guidelines do not change for an adult or a child. The examinations history, review of systems and all other areas must be completed.

H. Terry Hutchison, MD, PhD, director of the Rehab Center for Pediatric Neurology at Valley Childrens Hospital Specialty Medical Group Inc., an integrated pediatric healthcare system in Madera, Calif., says that third-party payers would attempt to reduce higher level examinations on the grounds of a minimal review of systems and past medical history. He suggests countering this with detailed documentation of developmental and family history.

Developmental and family history with pediatric patients are two factors that can be the equivalent of past medical history and review of systems for adults, Hutchison says. When he receives denials for level four or level five claims, he fights the claims emphasizing these factors.

Roski agrees that documentation is crucial. If a neurologist has solid documentation, he or she should send back such claims and fight denials, stressing that the guidelines have been met.

Coding by Time

Neurologists have the choice of choosing an E/M level based on history taking, examination and level of decision-making or by time if more than 50 percent of the patient encounter was spent on counseling and coordination of care.

We may spend an hour-and-a-half performing a new patient examination on a child, says Hutchison. He reports that although an adult neurological examination generally proceeds in a predetermined sequence with the neurologist checking cranial nerves, muscles, reflexes, sensation, and other factors, gaining the same information from a child can be quite difficult. The child may be restless or uncooperative for any number of reasons, and the information has to be acquired in a piecemeal fashion.
Roski agrees that acquiring information from a child often will take longer and adds, HCFA has emphasized over and over again that time is a very legitimate fall back position for choosing E/M levels. He suggests stating in the patient charts exactly how much time is spent face-to-face with the patient.

Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., that consults with several neurology practices, adds the following example: The physician documents that he started history-taking at 9:05 a.m. and finished at 9:20 a.m. (or he started the history at 9:05 a.m. and finished at 9:55 a.m.) Then, during the same session, tests were ordered and performed on the patient. The test results were obtained, and the neurologist spoke to the childs parent or guardian. He needs to document that he started to counsel them at 10:15 a.m., and it went until 11:15 a.m. The total exam would then be a level five by time alone, says Brink.

Brink adds that treatment for coexisting conditions also may serve to justify billing a higher level E/M code. The child may be afflicted with muscular dystrophy (359) as well as aphasia (784.3) or autism (299.0), Brink says. Many pediatric neurology patients have additional medical problems that require additional time and care.

Roski says that the review of records also contributes greatly to the medical decision-making portion of the visit. Brink agrees that review of records is a major factor in determining the overall E/M level to bill for the patient encounter. If a pediatrician has followed a 3-year-old with neurological problems, the pediatrician likely performed a comprehensive examination (including history, exam and medical decision-making) at some point. The neurologist would need to review such records prior to the medical exam, and the time spent in that review process should be referenced.

Using a Pediatric Neurological Exam Template

The formulas for the CPT E/M level of service, as well as the single-system exam, are not memorized easily, so having these available on wall-mounted charts is critical, Cohen says.

Several notable neurologists are working toward the creation and the HCFA approval of an official pediatric neurological examination template. In the meantime, many neurologists have created templates to focus on the areas addressed when examining children.