Part B Insider (Multispecialty) Coding Alert

Published on Sun Dec 12, 2004 PDF

Neurologists confused by non-paying t-PA code

One sure way to throw away valuable reimbursement: Bill for t-PA by itself.

CPT 37195 (Thrombolysis, cerebral, by intravenous infusion) carries 8.08 relative value units, but none of those are assigned to "physician work." The code only covers the facility's expense for t-PA administration.

Neurologists very frequently ask how to handle this quandary, reports Mark Nuwer, a neurologist who represents the AAN on the American Medical Association's CPT Advisory Committee.

Faced with this tricky situation, some neurologists have tried to bill 37201 (Transcatheter thrombolysis) instead, because that code contains physician work values. But the American Academy of Neurology warns that 37201 involves a service delivered under radiological control through an arterial catheter by a radiologist or cardiologist. The code is not appropriate for t-PA administration.

Luckily, the physician can bill for evaluation and management along with the t-PA administration. In fact, there are four separate options to obtain a reward for the hard work the physician does in managing a stroke patient: critical care services (99291-99292), prolonged care services (99356-99357), initial inpatient care (99221-99223), or initial and follow-up consultation codes (99251- 99255, 99261-99263).

Of these, critical care is usually the most appropriate, say experts. "I'm not sure I would ever use the word 'never' or 'always' when dealing with CPT stuff," but generally critical care is appropriate with stroke patients, says Nuwer.

By definition, when you're considering using t-PA with a patient, "it's by definition a critical care situation, and [patients] are not just critically ill, they're also unstable," says Nuwer. "The situation could change at any moment to something a lot worse." On average, he estimates a patient receiving t-PA will need two and a half hours of critical care, or one unit of 99291 (first 30-74 minutes) and three units of 99292 (each additional half hour).

The physician usually decides whether to claim critical care, notes Laurie Castillo, president of Professional Coding & Compliance Consulting in Manassas, VA. The coder can't bill for critical care unless the physician marks it clearly and records the time spent in some detail. Usually, there are other factors going on besides the t-PA administration that require critical care.

You can use prolonged services if the physician spends a lot of time with the patient but the documentation doesn't support critical care. You may also be able to bill for an initial hospital visit in addition to critical care or prolonged care, if the physician provides t-PA on the patient's first day in the hospital.