Neurology & Pain Management Coding Alert

After ordering a test to rule out a possible condition, a neurologist may encounter a reimbursement dilemma because of a variety of coding possibilities. This scenario can be complicated further if a suspected problem exists rather than the problem ruled out by the testing.

You cant code based on the lab finding or the x-ray alone, says Bruce Cohen, MD, co-director of the Brain Tumor Center at the Cleveland Clinic Foundation in Cleveland, which has more than 40 neurologists. But if the diagnosis is not known before the test is done, the claim should be coded based on the signs and symptoms noted by the neurologist when the test was ordered.

Case Example

When a patient has generalized convulsive epilepsy (345.11) that is nonresponsive to medication, the neurologist wants to rule out other medical conditions, such as aneurysm (747.81) or brain tumor. Cohen asserts that Selecting the correct code when ordering a test should be substantiated by what is in the physicians note. When formulating an assessment of a patient, the term rule-out brain tumor, for example, is not appropriate.

When ordering an MRI or CT scan for a patient with headaches, the neurologist needs to provide justification in the medical record, as well as provide an acceptable diagnostic code that the insurance company will find is a justifiable cause for ordering that test, he says.

Cohen adds, An EMG would probably never be a reasonable test for a patient presenting with a headache. Likewise, neurologists do not order MRIs to prove a patient has migraines or tension headaches; they order MRIs for patients with headaches and other historical or physical findings suggestive of underlying pathology to prove or disprove that suspected illness. Therefore, code the epilepsy as the primary code and do not code the medical condition that the neurologist is seeking to rule out.

Cohen gives another example. A patient is having a progressive headache disorder in which mild, infrequent headaches occur and are accompanied by nausea and vomiting in the morning. This is suggestive of a brain tumor, Cohen says. A neurologist should do a CAT scan to investigate the possibility of a brain tumor. Insurance companies wont pay for CAT scans for migraines, so if you code the CAT scan as a test for migraine, its an instant rejection, he says.

Neurologists should avoid using unconfirmed diagnosis codes because insurance companies maintain databases of such codes. When people apply for life, health or disability insurance, the insurance company will look for any problems they had in the past. For example, do not use the diagnosis code for a congenital brain aneurysm (747.81) for a CAT scan if the signs and symptoms were for epilepsy (345.10). Otherwise, the patient will end up with a permanent history on his or her medical record of having had a brain aneurysm, and this could have serious effects on future insurability.

Coding the Secondary Diagnosis

Although there are no codes for rule-outs, secondary diagnosis codes can be very useful in a typical rule-out scenario. Insurance companies, however, dont always pay attention to a secondary diagnosis.

When coding a CAT scan of the brain for a patient with recurrent convulsions (780.39) and headaches (784.0), code 780.39 for the first diagnosis, but have 784.0 on the form in case you have to order CAT scans and MRIs over a period of time. Having both on the form ensures that when the claim is reviewed the patients recurring convulsions and headaches will be clear even if the insurance company missed it when it initially processed the claim.

Follow-up Diagnoses

Assume a CAT scan shows that a patient has a benign neoplasm of the brain (225.0). The neurologist sees the patient for a follow-up and wants another CAT scan to see if theres been any change. This time only one diagnosis code is needed for this test. Because the brain tumor is the reason the patient is coming in for the follow-up, it is also the reason for the second CAT scan, says Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J. As long as the patient is being treated for the benign brain tumor, use the code for the CAT scan as well as for the office visit. If the patient comes in for a follow-up after having undergone surgery to remove the brain tumor and the CAT scan no longer shows any evidence of the tumor, then use diagnosis code V67.0 (follow-up examination).

Brink advises using the V67.0 for exams following surgery only if no new or recurring problems are found. The V67 codes are for follow-up exams after a condition has healed. A patient coming in for a six-month follow-up visit for a brain tumor surgery with no recurrence would be V67.0. This is not during the healing phase, says Brink, but after completed treatment. However, if there was a recurrence, you should also use the appropriate code for malignant neoplasm of the brain.

Some veteran coders may see a potential problem here. In the real world, many insurance companies automatically deny claims with a V code as the primary diagnosis, despite the fact that coders follow coding rules and are compliant. The first code often is the only one they read. Payers may have their own guidelines, and neurology coders should request written copies of them when claims are denied for coding reasons, so coding actions can be justified if there is an audit.

As long as the doctor provides a code in good faith, there should not be a problem even if the patient does not end up having the disease the physician was investigating. Under no circumstances should a physician misrepresent the truth to get a test covered and again, the physician will be protected as long as the proper justification is available in the patients medical record.