Cohen, Bruce H. MD, FAAN
CPT (Current Procedural Terminology) is a system organized and administered by the American Medical Association and contains the codes and definitions that describe the procedures used to care for patients. Evaluation and Management (E/M) codes are a small component of CPT and describe the cognitive services provided to patients. As cognitive specialists, most care given by neurologists who care for patients with brain tumors and the neurologic complications of cancer falls under E/M services, which include office visits, hospital visits, and other direct face-to-face services that require no special technology.
Proper coding for E/M requires correct identification of the specific type of patient encounter. Questions to ask include the following:
1. Is this an inpatient or outpatient encounter?
2. Is this a consultation? If so, does the insurance carrier allow me to bill for a consultation?
3. Is this a new patient or an established patient?
4. What level of service was provided to the patient?
The first three questions are straightforward (although the definition of a consultation is often misunderstood). A consultation is a request for an opinion from a physician or other qualified health care provider. If the patient’s insurance carrier covers consultations, a member of your group (another neurologist as well) can request a consultation. In general, an outpatient referral made so that you will assume the ongoing care of that patient is not a consultation. If the intent is for the patient’s care to be transferred to you, this should not be considered a consultation or new patient but an established patient. Likewise, if the patient comes from outside the practice, if the intent is for you to assume ongoing care, that patient should be given a new patient code. Admittedly this can be difficult to determine, which is one reason the Centers for Medicare & Medicaid Services has done away with consultation codes.
How to Select the Proper E/M Code
There are two different ways to choose the level of service:
1. The bullet system, which relies on meeting set standards of “bulleted” elements to determine the level of billing
2. The time-based system, which relies on the total time of the visit when the counseling and coordination of care account for more than 50% of the time of the visit
Neuro-oncology patients, like other patients with complicated neurologic illness, often require evaluation or treatment that qualifies for higher levels of medical decision making (MDM), thus potentially increasing the level of service for a visit. In such cases, when it is apparent that MDM is high, be sure to gather adequate history and perform adequate examination elements to fulfill that higher level of service by the bullet system.
Likewise, the extra time spent with patients may qualify for coding by time rather than bullets. If using the time-based coding, the document must state the following:
* the number of minutes spent face-to-face
* that more than 50% of the time was spent on counseling/coordination of care
* a general idea of what the counseling/coordination of care involved
Time is either face-to-face with the patient or family (outpatient) or bedside and on the unit or floor (inpatient). The rest of the note can be whatever is appropriate for good patient care.
Example 1: A neurologist was asked by a neurosurgeon to consult on the care of a 45-year-old man with a glioblastoma. The patient had had surgery 2 weeks ago after presenting with a series of seizures and had already seen the radiation oncologist. The neurologist reviewed the MRI films from before and after surgery and the pathology report and engaged in a discussion with both the neurosurgeon and radiation oncologist before recommending temozolomide chemotherapy. The neurologist also addressed the issue of dexamethasone taper, anticonvulsant use, and seizure management.
Analysis: This is a high level of MDM because, although one could argue that management options in this patient’s situation are limited, the amount of data to review reaches the high complexity based on Marshfield Clinic Criteria and the risk of morbidity and mortality is also quite high, based on the diagnosis. If a comprehensive history and physical examination is performed, this encounter could be billed as a level 5 outpatient consult (99245) using the bullet method. Time-based billing could be used in this situation, but given the work needed to be performed in order to best care for the patient, bullet-based billing is more important.
Example 2: A patient with a cerebellar pilocytic astrocytoma of the cerebellum resected 5 years ago returned to his neurologist for a routine visit. He reported no symptoms and his MRI was interpreted as showing “no change,” but the neurologist did not review the MRI. The patient told the neurologist he felt great and had had no contact with doctors since his last appointment 2 years ago. The neurologist asked a few questions and the patients’ responses convinced the neurologist that he was well. The patient reported that he was in college and played on the baseball team. The neurologist performed an examination touching on 12 examination items.
Analysis: In this example, the neurologist performed an expanded problem-focused history and a detailed examination, but the decision-making aspect of this office visit is straightforward or low. This is an outpatient level 3 established patient visit (99213) based on the history and examination elements. This visit will usually take 15 minutes. There are few ways to get this visit at the 99214 level.
Example 3: An established patient with a glioblastoma completed his radiation therapy and finished two cycles of chemotherapy. In the past week he developed headaches, and the neurologist asked three questions about the quality of these headaches and two questions that could be related to review of systems. He developed left arm weakness over the past day. His MRI showed clear progression of the mass with midline shift, and the neurologist discussed the MRI with the radiologist to get his thoughts about tumor progression versus radiation necrosis and with the neurosurgeon to see if additional surgery would be possible. The neurologist completed a comprehensive physical examination.
Analysis: The MDM in this case is high based on the work done and the high risk involved given the diagnosis. The history is probably at the “expanded problem-focused” level, but with established patients only two of the three key elements are needed to select the level of service. On the basis of the high level of MDM and the comprehensive examination, the most appropriate code is 99215.
Example 4: A long-time patient came to see his neurologist to discuss end-of-life decisions. The patient had been through many rounds of surgery, radiation therapy, and chemotherapy, but an MRI 2 days ago showed progression. The platelet count of 48,000/µL had not recovered since chemotherapy ended 3 months ago. Following some brief social exchange lasting 5 minutes, the neurologist realized the patient was exhausted and wanted to discuss the future. The neurologist spent the next 35 minutes discussing the expected natural progression of the illness and palliative options and introducing the palliative care team to the patient. The neurologist documented the highlights of the discussion and the fact that more than 50% of the patient encounter that lasted 40 minutes was spent with counseling and coordination of care.
Analysis: This visit meets the criteria for 99215, a level 5 outpatient established patient visit, based on the time criteria. The neurologist does not need to perform or document any history or examination (however standard medical care would suggest this may be appropriate), and the level of MDM is also not relevant.
Example 5: A neuro-oncologist was running a phase II study for a novel drug. Another neuro-oncologist requested a consultation on a patient because the patient qualified for the study but had questions about the study drug and the consulting doctor’s medical center provided several treatment options not available elsewhere. The consulting doctor spent 80 minutes face-to-face going over all treatment options. Essentially 100% of the time was spent counseling the patient.
Analysis: This patient does not need another history or physical examination— his referring doctor has done a great job of management. Both the referring doctor and patient only want the consulting neuro-oncologist’s opinion. Like example 4, this visit also meets the criteria for 99215, a level 5 outpatient established patient visit, based on the time criteria.
OTHER TYPES OF E/M SERVICES
Prolonged Visit Codes
E/M time for these codes is considered “to the closest hour,” and the first hour is any time between 31 and 74 minutes. If 31 minutes is not reached, you cannot bill. If the time is between 31 and 74 minutes, 1 hour of time can be billed, and if the time is from 76 to 104 minutes, an additional 30 minutes can be billed. The 30-minute codes are used for repeated (and not necessarily consecutive) time spent, using 15 minutes on either side as a factor in determining when each additional 30-minute code can be added. In reality these codes are seldom used in the outpatient setting (an end-of-life discussion is one example where it could be used). In the inpatient setting, if many hours a day (not necessarily continuous) are spent on a patient in the intensive care unit these codes may be used on occasion.
In some states, a doctor must record the start and end clock times for each patient. It is a good idea in all instances to put the exact amount of time within the body of the note, regardless.
Prolonged Care Codes
99354: First hour of prolonged outpatient service (31 to 74minutes), face-to-face
99356: First hour of prolonged inpatient service (31 to 74 minutes), face-to-face
99358: First hour of prolonged service (31 to 74 minutes), not face-to-face, on a day prior to or after an E/M visit
Prolonged care codes are used when service involving direct patient contact exceeds the usual, and they are reported in addition to the appropriate E/M code for the evaluation. The face-to-face codes are reimbursed by most carriers.
The reason and time taken for the prolonged service must be included in the note.
If the prolonged service takes longer than 90 minutes (ie, 91 minutes or more), other codes are available for the extra time: 99355 for each additional 30 minutes on an outpatient service and 99357 for each additional 30 minutes on an inpatient service. 99355 or 99357 cannot be billed unless you have gone 30 minutes past the initial 74 minutes (see above for that code). In this case you would bill for the initial service (99214 for a level 4 established patient, for example), 99354 for the next 60 to 74 minutes, and 99355 for anything that takes the visit an additional 15 to 44 minutes to an additional 75 to 104 minutes.
Hospital Discharge Day Codes
99238: 30 minutes or less
99239: more than 30 minutes
The discharge day is coded as hospital discharge day management. This code allows the attending physician to summarize all services on the day of discharge (ie, final examination, discussion, instructions, and record preparation). Time need not be continuous. Total time must be documented.
CPT CODES FOR NEURO-ONCOLOGISTS
Chemotherapy Codes 96401-96549
These codes are used for the administration of nonradioactive chemotherapy and biologic agents and are differentiated from the usual medication administration codes 96360-96379 on the basis of how toxic these medications may be and how much staff work is involved in terms of monitoring the infusions.
Codes 96401, 96402, 96409-96425, and 96521-96523 are not to be used in the facility setting. Facilities are entities that may report services in addition to the physician for the same service. Use of these codes must be discussed with a practice manager because of the nuances regarding practice setting.
62270 Diagnostic lumbar puncture
62272 Therapeutic lumbar puncture