Neurology & Pain Management Coding Alert

(Editors note: This is part two of a two-part article. The first section can be found in the February issue of Neurology Coding Alert.)

Neurology coders need to understand when it is appropriate to code signs and symptoms rather than the final diagnosis for an EEG study so that significant reimbursement is not lost. Additionally, by learning when it is and is not appropriate to bill for digital analysis, audits and costly paybacks can be avoided.

Symptom-based ICD-9 Coding

If a person is referred to my lab with a question of rule-out seizures and the EEG is normal, payment for it may be denied by the insurance company because they dont accept the rule-out diagnosis, says Larry Seiden, MD, assistant professor of neurology and director of the University of Maryland Center for Sleep Disorders.

For example, a referring primary care physician (PCP) believes a patients signs and symptoms may be indicative of seizures, but not likely. If this possibility was not investigated and the patient later turned out to have seizures, the PCP may have been at a malpractice risk. To cover his or her bases, he or she refers the patient to Seiden to rule it out. Medicare and most third-party payers will not cover tests linked to a diagnosis that is unconfirmed due to concerns about unnecessary testing. For this reason, Seiden recommends coding the EEG based on the symptoms that first caused concern, not the unconfirmed possible diagnoses of seizures.

In another example, a patient complains of blackouts (fainting spells). The neurologist believes they may be the result of seizures but, to test for this, performs an EEG. Because a possible or rule-out diagnosis of seizures will lead to a denial, the neurologist codes for the symptoms of either fainting spells (780.2) or brief loss of consciousness (780.09) along with 95819 for the awake and asleep EEG.

Medicare will deny unspecified diagnosis codes because they do not provide the medical necessity for the EEG, warns Erwin Montgomery, MD, director of the movement disorders program for the Cleveland Clinic in Cleveland, which has more than 40 neurologists on staff.

For example, a patient presents with memory loss, and the neurologist runs an EEG. If 780.9 (other general symptoms including amnesia [retrograde], chill[s], generalized pain, hypothermia, etc.) is used as the diagnosis linked to the procedure, insurance companies may not pay because the diagnosis definition, while including amnesia, also lists many unrelated conditions. Such diagnoses are generally not on a carriers list that denotes medical necessity. The coder should choose another one that also describes the problem, such as organic brain syndrome (310.9), which is normally covered. Montgomery says the neurologist should contact his or her local [...]