Neurology & Pain Management Coding Alert

Test your coding knowledge.  Determine how you would code this situation before looking at the box below for the answer.
Question: I have been advised that an MMSE performed on the same day as an E/M service should be included in that service. How should I do this? Should I upcode one level?

South Carolina Subscriber

    Answer: Mini-mental state exams (MMSEs) are not separately reimbursable by Medicare so an MMSE does not automatically raise the level of an E/M service. Choose E/M levels according to the three components of exam, history and medical decision-making. Only if the MMSE contributes significantly to these components can a higher-level E/M service be reported. 
 
If counseling and coordination of care consume more than 50 percent of the visit, time can be used as the determining factor for most E/M services. For instance, if, after undergoing an MMSE, an established patient discusses his or her condition with the physician (or the physician discusses the patient's condition with the patient's family) for 40 minutes of a 55-minute visit, the visit may be coded 99215 (office or other outpatient visit for the evaluation and management of an established patient ...) based on time alone. When reporting E/M services based on time, maintain careful documentation outlining the time spent face-to-face, counseling or coordinating care, with the patient or family.
 
Do not report 96115 (neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning] with interpretation and report, per hour) for an MMSE. Although some payers may reimburse the claim, this is improper coding and may result in penalties if it is discovered during an audit.