Neurology & Pain Management Coding Alert

Shifting costs to patients may be the only way to avoid losses

If your neurology practice provides Apokyn services for patients with Parkinson's disease, your reimbursement opportunities are generally limited to reporting E/M services.

To be sure to get the pay you deserve for Apokyn-related services, consider three reimbursement solutions. 1. Make the Most of E/M Visits Because E/M services provide the only opportunity to bill for Apokyn, don't allow poor documentation to diminish the E/M level you can report.

Many Medicare carriers won't cover Apokyn (apomorphine) because the patient can self-administer the drug. But a physician must evaluate the patient prior to prescribing Apokyn. And the patient will usually receive his first injection in the physician office so the physician can evaluate the effectiveness of the drug and watch for any side effects, says Marc Raphaelson, MD, a neurologist in Frederick, Md., and a member of the AAN's medical economics and management committee. These visits represent legitimate reimbursable services. Look to Level 4 or 5 for Evaluation Visit The complexity of the E/M service during which the neurologists considers prescribing Apokyn means that you should report a high-level service (for example, 99215, Office or other outpatient visit for the evaluation and management of an established patient ...) for most patients. To claim this service successfully, however, the neurologist must document his work thoroughly.

To determine whether a patient is a suitable candidate for Apokyn, the neurologist must take a thorough history from the patient, says P. David Charles, MD, associate professor, director of the Movement Disorders Clinic and director of the Residency Training Program in Neurology at Vanderbilt University, Nashville, Tenn.

Specifically, the neurologist must determine whether the patient is having sudden, unexpected "off" episodes that affect his daily quality of life. The neurologist must also pay attention to any medication side effects or interactions, as well as any history of cardiac disease or orthostatic hypotension, which requires special caution, Charles says. And the neurologist must determine whether  the patient can tolerate the anti-nausea drug trimethobenzamide, which the patient must take for at least three days before the first dose of Apokyn.

The neurologist's documentation should note not only  the additional time required for such a visit but also the increased levels of history, exam and MDM.
 
Initial Injection Calls for Another High-Level E/M Once again, when the patient arrives for his "trial" Apokyn injection - and if the neurologist documents his effort - you should report a high-level E/M service.

Administering the patient's first dose of Apokyn is a complex and time-consuming matter, Raphaelson says. "It takes a lot of patient time in the office," he says.

Before administering the injection, the neurologist should review and document the following, which will [...]