Neurology & Pain Management Coding Alert

Question: We had a new patient come in suspecting that he was suffering from carpal tunnel syndrome. During the neurologists evaluation, high blood pressure was discovered. Most of the visit was spent trying to determine the cause, and the physician wanted to charge a level four visit. But to bill this, HCFA states that the doctor must review at least four history of present illness (HPI) categories. However, when talking about blood pressure, only one category was reviewed (plus one additional category for the patients carpal tunnel syndrome). This lowers the visit to a level two. Is there any way to boost this?

Alabama Subscriber

Answer: If, based on your documentation, you havent met the criteria to bill a 99204, you should refer to the more appropriate code (probably 99202 or 99203, depending on your documentation). There are circumstances under which you can code by time rather than by the three key elements (HPI, exam, and medical decision-making). If the neurologist was able to document that the time spent counseling and coordinating the patients care comprised more than half of the session, you can code accordingly.

For instance, if the visit only warrants a 99202, but the neurologist spent thirty-minutes with the patient, twenty minutes of which involved counseling or coordinating care, then the visit could be coded as a 99203 because this code reads, Physicians typically spend 30 minutes face-to-face time with the patient and/or family. The extent of counseling or coordination of care must be documented in the patients medical record. For example, you would report the visit as usual, but would add, discussed the patients diet and exercise routine. Talked at length about his stress level at work and advised him on ways to reduce his blood pressure. Discussed these issues with the patient for 20 minutes of a 30-minute visit.