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CONTINUUM: Lifelong Learning in Neurology:
doi: 10.1212/01.CON.0000429191.21084.20
Practice Issues

Coding for Behavioral Neurology

Hart, John Jr MD; Womack, Kyle B. MD; Powers, Laura B. MD, FAAN; Nuwer, Marc R. MD, PhD, FAAN

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Author Information

Address correspondence to John Hart Jr., MD, Center for BrainHealth, 2200 W. Mockingbird Ln. Dallas, TX 75235

Relationship Disclosure: Dr Hart has served on the speakers bureau for Forest Laboratories, Inc, and as a medicolegal consultant. Dr Womack has received research support from Allon Therapeutics, Inc, and Bayer AG. Dr Powers serves as ICD-9-CM Advisor for the Coding Subcommittee of the AAN Medical Economics and Management Committee and serves in an editorial capacity for Neurology: Clinical Practice. Dr Nuwer serves as a medical reviewer for SleepMed.

Unlabeled Use of Products/Investigational Use Disclosure: Drs Hart, Womack, Powers, and Nuwer report no disclosures.

Accurate coding is an important function of neurologic practice. This contribution to CONTINUUM is part of an ongoing series that presents helpful coding information along with examples related to the issue topic. Tips for diagnosis coding, evaluation and management coding, procedure coding, or a combination are presented, depending on which is most useful for the subject area of the issue.

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EVALUATION AND MANAGEMENT

Evaluation and Management (E/M) coding in behavioral neurology is complicated by the length of time required to perform both a standard neurologic evaluation and the additional and more extensive neurobehavioral examination. The Mini-Mental State Examination does not fulfill the requirements for the neurobehavioral status examination, which must include “clinical assessment of thinking, reasoning, and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities.”1 These two components have distinct and somewhat independent coding implications. The optimal way to document the neurobehavioral examination is with a separate report that includes the tests administered, results, interpretation of the results, as well as time spent. There are two choices for billing:

1. Current Procedural Terminology (CPT) E/M code plus CPT code 96116 for neurobehavioral status examination (the most conventional choice)

2. Coding by time alone with E/M code plus prolonged service codes, and bundling both services into one

The following is a case example of a plausible behavioral neurology consultation.

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Case

A 68-year-old patient who was new to the clinic presented with her spouse with the chief complaint of slowly progressive memory problems that had been occurring over the past 2 years. This problem had not gotten her fired from her job, but she found she needed to double-check everything she did and think much harder than before to complete tasks. She was fatigued in the evenings and said that it took “12 hours of mental energy to do what was previously an 8-hour job.” At home, she found keeping up with receipts and checks more difficult than in the past. She was unaware of any other neurologic deficits, although her husband had noted an occasional tremor of her hands for the past 6 months. She still played bridge with friends monthly but had some problems remembering what cards had been played. She had never become lost while driving. She felt no depression, although she admitted feeling anxious, especially about losing her job. Current medications were hydrochlorothiazide and atorvastatin. She had a history of treated and controlled hypertension and high cholesterol and a family history significant for a mother with autopsy-confirmed Alzheimer disease. She drank two to three drinks each night after work but less on the weekend. Review of 14 systems was documented in her chart. Notable positives included anxiety, negative ruminations, lack of energy, and sleep disruption.

On examination the patient appeared healthy. Her blood pressure was 130/72 mm Hg, her pulse was 70/min, and her weight was 68 kg (150 lb). There were no carotid bruits, or cardiac murmurs, and peripheral pulses were normal. She was alert and oriented to time, date, and place. She could name 3/3 common objects and recall 2/3 objects after 5 minutes; her fluency was 10 words that begin with the letter F in 1 minute. Fund of knowledge was good, and she attended well. Optic fundoscopy was normal. Visual fields were full to confrontation, and she had full extraocular movements. Facial sensation was normal. Her face was symmetric and moved normally. Hearing was intact to whisper. Palate moved symmetrically. Sternocleidomastoid muscles were normal in strength. Her tongue protruded in the midline and moved normally. Sensation was normal to touch, pinprick, vibration, and joint position sense. Muscle tone and strength were normal in four extremities. A mild resting tremor of the hands was present. Reflexes were normal and symmetric, and toes were downgoing with plantar stimulation. Finger-to-nose and heel-to-knee-to-shin coordination were normal, and there was no Romberg sign. Gait was normal.

The patient was administered the following neurobehavioral tests: attention (digit span), verbal fluency (Controlled Oral Word Association Test), naming (15-item version of the Boston Naming Test), verbal episodic memory (Hopkins Verbal Learning Test), visuoconstructional skills (the copy condition of the Rey-Osterreith Complex Figure test), and executive and cognitive control functions (Trail-Making Test Parts A and B). The patient scored approximately 1.75 standard deviations (SD) below the mean on verbal episodic memory but otherwise performed around the mean on the other tests.

The impression was that the patient had amnestic mild cognitive impairment. Further evaluation included ordering a brain MRI, laboratory studies, and referral for evaluation for possible anxiety disorder. Counseling surrounding her diagnosis, alcohol use, anxiety level, and employment status concerns was given.

Total time spent face to face was 1 hour and 40 minutes. Thirty-five minutes were spent with the neurobehavioral examination. Of the remaining 65 minutes, 40 minutes were spent in counseling and coordination of care.

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Discussion

Using the conventional reporting method, the E/M code for the new patient visit, level 4 (99204), is billed with a code for the separately reported neurobehavioral status examination (96116). Also note that a five-bullet mental status examination must be reported separately from the neurobehavioral status examination to qualify for using 99204 and 99205. The total visit time for the E/M code is 65 minutes and for the neurobehavioral examination, 35 minutes. The “typical” time for code 99204 is 45 minutes; therefore, code 99205 may be used instead of 99204 based on time (typical 60 minutes for 99205), with the documentation that more than 50% of that time was spent on counseling and coordination of care. Code 96116 is billed “per hour” of face-to-face time. An hour is 31 to 90 minutes in the CPT world, so 96116 may be used here. Had the time been shorter, the examination must be bundled into the E/M code.

A second method of coding would not require a separate report (although the neurobehavioral status examination information should be included in the chart). Prolonged service codes 99354 (first hour 30 to 74 minutes) and 99355 (each additional time up to 30 minutes) are used for face-to-face time spent beyond the typical time for an E/M service. For this visit of 140 minutes, 99204 would be reported with 99354 and 99355. The counseling and coordination of care coding method would not increase the level of the E/M code because the counseling time is less than 50% of the total time spent. In both cases, the specific documentation of time is paramount! Reimbursement rates change yearly and vary by region, so absolute numbers are not given here. For 2013, billing 99204 with 99354 and 99355 has a higher reimbursement than billing 99205 with 96116, but the face-to-face encounter must total more than 134 minutes to use the first set of codes. The caveat to bundling the two individual examinations is that payers might eventually insist that the neurobehavioral status examination is a part of the E/M service and not billable separately.

Regardless of coding prolonged services time or the neurobehavioral examination, the E/M level of complexity or decision making for this neurologic consultation should take into account that both interpretation of the results of neurobehavioral testing in conjunction with the history and the neurologic examination are used in the diagnostic formulation.

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ICD-10-CM CODING

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)2 codes will be replaced on October 1, 2014, with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes.3 Only billing claims using the new codes will be accepted as of that date. ICD-10-CM codes are up to seven characters long and alphanumeric. The first character is the letter corresponding to the chapter (body system). A partial overview of relevant new behavioral neurology codes follows (note that, for space reasons, codes for dementia associated with behavioral disturbance have been omitted).

ICD-9-CM Code ICD-10-CM Code

290.0 Senile dementia, uncomplicated F03.90 Unspecified dementia without behavioral disturbance

Includes: presenile dementia not otherwise specified (NOS), presenile psychosis NOS, primary degenerative dementia NOS, senile dementia NOS, senile dementia depressed or paranoid type, senile psychosis NOS

Excludes1: senility NOS (R41.81)

Excludes2: mild memory disturbance due to known physiologic condition

senile dementia with delirium, or acute confusional state (F05)

290.10 Presenile dementia, uncomplicated F03.90 Unspecified dementia without behavioral disturbance

Includes: presenile dementia NOS, presenile psychosis NOS, primary degenerative dementia NOS, senile dementia NOS, senile dementia depressed or paranoid type, senile psychosis NOS

Excludes1: senility NOS (R41.81)

Excludes2: mild memory disturbance due to known physiologic condition

senile dementia with delirium, or acute confusional state (F05)

290.13 Presenile dementia with depressive features F03.90 Unspecified dementia without behavioral disturbance

Includes: presenile dementia NOS, presenile psychosis NOS, primary degenerative dementia NOS, senile dementia NOS, senile dementia depressed or paranoid type, senile psychosis NOS

Excludes1: senility NOS (R41.81)

Excludes2: mild memory disturbance due to known physiologic condition

senile dementia with delirium, or acute confusional state (F05)

290.20 Senile dementia with delusional or depressive features F03.90 Unspecified dementia without behavioral disturbance

Includes: presenile dementia NOS, presenile psychosis NOS, primary degenerative dementia NOS, senile dementia NOS, senile dementia depressed or paranoid type, senile psychosis NOS

Excludes1: senility NOS (R41.81)

Excludes2: mild memory disturbance due to known physiologic condition

senile dementia with delirium, or acute confusional state (F05)

F05 Delirium due to known physiologic condition

Acute or subacute brain syndrome

Acute or subacute confusional state (nonalcoholic)

Acute or subacute infective psychosis

Acute or subacute psycho-organic syndrome

Delirium of mixed etiology

Delirium superimposed on dementia

Sundowning

Code first the underlying physiologic condition.

Excludes1: delirium NOS

Excludes2: delirium tremens alcohol-induced or unspecified (F10.231, F10.921)

290.40 Vascular dementia, uncomplicated F01.50 Vascular dementia without behavioral disturbance

Use additional code to identify cerebral atherosclerosis (437.0) or other condition resulting in this diagnosis.

Includes: arteriosclerotic dementia

Code first the underlying physiologic condition or sequelae of cerebrovascular disease.

291.1 Alcohol-induced persisting amnestic disorder F10.96 Alcohol use, unspecified, with alcohol persistent memory disorder

291.2 Alcohol-induced persisting dementia F10.27Alcoholdependencewithalcohol-inducedpersistingdementia

293.0 Delirium due to conditions classified elsewhere F05 Delirium due to known physiologic condition

Code first the associated physical or neurologic condition.

Includes: acute or subacute brain syndrome, acute or subacute confusional state (nonalcoholic), acute or subacute infective psychosis, acute or subacute organic reaction, acute or subacute psycho-organic syndrome, delirium of mixed etiology, delirium superimposed on dementia, sundowning

Code first the underlying physiologic condition.

Excludes1: delirium NOS (R41.0)

Excludes2: delirium tremens alcohol-induced

294.0 Amnestic disorder in conditions classified elsewhere F04 Amnestic disorder due to known physiologic condition

Includes: Korsakov’sa psychosis or syndrome, nonalcoholic

Korsakoff’sa psychosis or syndrome (non-alcoholic)

Code first the underlying physiologic condition.

Code first underlying condition.

Excludes1: amnesia NOS (R41.3), anterograde amnesia (R41.1), dissociative amnesia (F44.0), retrograde amnesia (R41.2)

(This is also the default code for posttraumatic amnesia.)

Excludes2: alcohol-induced or unspecified Korsakov’s syndrome (F10.26, F10.96), Korsakov’s syndrome induced by other psychoactive substances (F13.26, F13.96, F19.16, F19.26, F19.96)

294.10 Dementia in conditions classified elsewhere without behavioral disturbance

F02.80 Dementia in other diseases classified elsewhere, without behavioral disturbance

Code first the underlying condition.

Dementia in other diseases classified elsewhere not otherwise specified

Code first the underlying physiologic condition.

294.8 Other persistent mental disorders due to conditions classified elsewhere F06.8 Other specified mental disorders due to known physiologic condition

Code first the underlying condition.

Code first the underlying physiologic condition.

294.9 Unspecified persistent mental disorders due to conditions classified elsewhere

F06.8 Other specified mental disorders due to known physiologic condition

Code first the underlying condition.

Code first the underlying physiologic condition.

310.2 Post-concussion syndrome F07.81 Postconcussional syndrome

Postcontusional syndrome (encephalopathy)

Post-traumatic brain syndrome, nonpsychotic

Use additional code to identify associated post-traumatic headache (G44.3-)

Excludes1: current concussion (brain) (S06.0-), postencephalitic syndrome (F07.89)

310.8 Other specified non-psychotic mental disorders following organic brain damage.

F07.89 Other personality and behavioral disorders due to known physiologic condition

(This is the “default” code for mild memory disturbance after brain damage.)

Postencephalitic syndrome

Right hemispheric organic affective disorder

Code first the underlying physiologic condition.

331.0 Alzheimer’s disease

G30.0 Alzheimer’s disease with early onset

Use additional code, where applicable, to identify dementia: with behavioral disturbance (294.11), without behavioral disturbance (294.10)

G30.1 Alzheimer’s disease with late onset

G30.8 Other Alzheimer’s disease

G30.9 Alzheimer’s disease, unspecified

Use additional code to identify: delirium, if applicable (F05); dementia with behavioral disturbance (F02.81); dementia without behavioral disturbance (F02.80)

331.11 Pick’s disease

G31.01 Pick’s disease

Circumscribed brain atrophy

Progressive isolated aphasia

Use additional code to identify: delirium, if applicable (F05); dementia with behavioral disturbance (F02.81); dementia without behavioral disturbance (F02.80)

331.19 Other frontotemporal dementia G31.09 Other frontotemporal dementia

331.6 Corticobasal degeneration G31.85 Corticobasal degeneration

331.7 Cerebral degeneration in diseases classified elsewhere.

G94 Other disorders of brain in diseases classified elsewhere

Code first the underlying disease.

Code first the underlying disease.

331.82 Dementia with Lewy bodies

G31.83 Dementia with Lewy bodies

Dementia with Parkinsonism

Lewy body dementia

Lewy body disease

331.83 Mild cognitive impairment, so stated G31.84 Mild cognitive impairment, so stated

Excludes: altered mental status (780.97), cerebral degeneration (331.0-331.9), change in mental status (780.97), cognitive deficits following (late effects of) cerebral hemorrhage or infarction (438.0), cognitive impairment due to intracranial or head injury (850-854, 959.01), cognitive impairment due to late effect of intracranial injury (907.0), cognitive impairment due to skull fracture (800-801, 803-804), dementia (290.0-290.43, 294.8), mild memory disturbance (310.8), neurologic neglect syndrome (781.8), personality change, nonpsychotic (310.1)

Excludes1:age related cognitive decline (R41.81), altered mental status (R41.82), cerebral degeneration (G31.9), change in mental status (R41.82), cognitive deficits following (sequelae of) cerebral hemorrhage or infarction (I69.01,I69.11, I69.21, I69.31, I69.81, I69.91), cognitive impairment due to intracranial or head injury (S06.-), dementia (F01.-, F02.-, F03), mild memory disturbance (F06.8), neurologic neglect syndrome (R41.4), personality change, nonpsychotic (F68.8)

331.89 Other cerebral degeneration, Other (Corticobasal degeneration)

G31.89 Other specified degenerative diseases of nervous system

(Dementia in) 332.0 Parkinson’s disease

G20 Parkinson’s disease

F02 Dementia in other diseases classified elsewhere

Use additional code to identify dementia, if present, from 294.10 to 294.11.

332.2 Senile degeneration of brain G31.1 Senile degeneration of brain, NEC

333.0 Other degenerative diseases of the basal ganglia G23.1 Progressive supranuclear ophthalmoplegia [Steele-Richardson-Olszewski]

Progressive supranuclear palsy (PSP) (Multiple system atrophy [MSA])

G23.2 Striatonigral degeneration

G23.8 Other specified degenerative disease of the basal ganglia

Includes: progressive supranuclear palsy

348.31 Metabolic encephalopathy G93.41 Metabolic encephalopathy

348.39 Other encephalopathy (Paraneoplastic encephalopathy) (Other non-neoplastic limbic encephalopathy)

G93.49 Other encephalopathy

349.82 Toxic encephalopathy G92 Toxic encephalopathy

Toxic encephalitis

Toxic metabolic encephalopathy

Code first (T51-T65) to identify toxic agent.

780.09 Alteration of consciousness, other R40.0 Somnolence

Drowsiness Drowsiness

Semicoma R40.1 Stupor

Somnolence Catatonic stupor

Stupor Semicoma

Unconsciousness

(This is the default code for delirium when no associated cause is known.)

780.93 Memory loss R41.1 anterograde amnesia

R41.2 Retrograde amnesia

R41.3 Other amnesia

780.93 Memory loss

R41.2 Retrograde amnesia

Amnesia (retrograde) R41.3 Other amnesia

Memory loss NOS Amnesia NOS

Excludes memory loss due to:

Memory loss NOS

Intracranial injuries(850.0-854.19)

Skull fractures (800.00-801.99, 803.00-804.99)

Excludes: amnestic disorder due to known physiologic condition (F04), amnestic syndrome due to psychoactive substance use (F10-F19 with fifth character .6), transient global amnesia (G45.4)

Mild memory disturbance due to organic brain damage (310.8)

Transient global amnesia (437.7)

781.8 Neurologic neglect syndrome

R41.4 Neurologic neglect syndrome

Asomatognosia Asomatognosia

Hemi-akinesia Hemi-akinesia

Hemi-inattention Hemi-inattention

Hemispatial neglect Hemispatial neglect

Left-sided neglect Left-sided neglect

Sensory extinction Sensory extinction

Visuospatial neglect Visuospatial neglect

784.3 Aphasia R47.01 Aphasia

Excludes aphasia due to late effects of cerebrovascular disease (438.11)

Excludes1: aphasia following cerebrovascular disease (I69. with final characters -20), progressive isolated aphasia (G31.01)

784.60 Symbolic dysfunction, unspecified

R48.9 Unspecified symbolic disturbance

Excludes developmental disorders

784.61 Alexia and dyslexia Alexia (with agraphia)

R48.0 Dyslexia and alexia

(If congenital, use 315.01)

Excludes developmental disorders

784.69 Other symbolic dysfunction, other R48.1 Agnosia

Acalculia Astereognosia (astereognosis)

Agnosia Autotopagnosia

Agraphia (absolute)

Excludes1: visual object agnosia (R48.3)

Apraxia R48.2 Apraxia

Anomia Excludes1: Apraxia following cerebrovascular disease (I69.with final characters -90)

R48.8 Other symbolic dysfunctions

Acalculia

Agraphia

All the above exclude developmental disorders.

799.51 Attention or concentration deficit R41.840 Attention and concentration deficit

Excludes1: attention-deficit hyperactivity disorders (F90.-)

799.52 Cognitive communication deficit R41.841 Cognitive communication deficit

799.53 Visuospatial deficit R41.842 Visuospatial deficit

799.54 Psychomotor deficit R41.843 Psychomotor deficit

799.55 Frontal lobe and executive function deficit R41.844 Frontal lobe and executive function deficit

799.59 Other signs and symptoms involving cognition

R41.849 Other signs and symptoms involving cognitive functions and awareness

a ICD-9-CM uses the spelling “Korsakoff,” whereas ICD-10-CM uses “Korsakov.”

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References

1. American Medical Association. Current Procedural Technology (CPT) 2012. Chicago, IL: American Medical Association Press, 2012.

2. Centers for Medicare & Medicaid Services, National Center for Health Statistics. ICD-9-CM official guidelines for coding and reporting. www.cdc.gov/nchs/data/icd9/icdguide10.pdf. Accessed October 18, 2012.

3. Centers for Medicare & Medicaid Services, National Center for Health Statistics. ICD-10-CM official guidelines for coding and reporting 2012. www.cdc.gov/nchs/data/icd10/10cmguidelines2012.pdf. Updated October 1, 2011. Accessed December 27, 2012.

© 2013 American Academy of Neurology

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