Janus, Todd J. PhD, MD, FAAN
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.
It is imperative in the evaluation and management of patients with multiple sclerosis (MS) to properly code for the often time-consuming and at times difficult patient encounters. By making educated, informed, and complete coding decisions, the practitioner can accurately and completely bill for the services provided.
Recent changes and future alterations in coding methods obligate the neurologist to be vigilant for any changes that can adversely affect billing and compensation. Since 1990, the diagnosis codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)1 have been used to report medical necessity on billing claims, including Evaluation and Management (E/M) visits. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)2 will be implemented for reporting diagnosis codes in the United States on October 1, 2014. Neurologists should be prepared well in advance (including using available American Academy of Neurology resources) to expedite changes in coding based on the new ICD-10-CM criteria.
CODING FOR MULTIPLE SCLEROSIS
The ICD-9-CM code for multiple sclerosis is 340.0. This code converts directly to ICD-10-CM G35 (Multiple sclerosis). Maintaining a single code makes physician coding easier, but some advantage exists in having the ability to further specify the type of MS in order to demonstrate medical necessity for certain treatments and also to provide assumptions of severity of illness for future risk stratification of patients for medical population management in new health care delivery models. As soon as a stable international classification system for MS is agreed upon, the ICD-10-CM will likely be expanded to include the various clinical variations of this disease.
Since currently only a single code is specified for MS, including additional codes for any new or recurring symptoms that were addressed during the visit may help indicate medical necessity and, to some degree, severity. For example, if a patient reports pain with urination, include 788.1 Dysuria (ICD-10-CM code R30.0). Patient complaints of fatigue (ICD-9-CM code 780.79, ICD-10-CM code R53.83) and numbness (ICD-10-CM code 782.0, ICD-10-CM code R20.0) can also be included. Codes for paraparesis, ataxia, visual field defects, and cognitive disturbance are indications of disability and support greater severity of illness. Specific codes for these can be found in the neurology and symptom chapters of both ICD-9-CM and ICD-10-CM.
In the unlikely event that a patient were to develop progressive multifocal leukoencephalopathy (PML) as a result of administration of natalizumab, the ICD-9-CM code for this is 046.3, but the record must include documentation of John Cunningham virus (JC virus) recovered from CSF or brain tissue. This code would be accompanied by code E933.1 for adverse effects of immunosuppressive agents. The ICD-10-CM codes are A81.2 for PML and T45.1x5A if it is the initial encounter, T45.1x5D for a subsequent encounter, and T45.1x5S if the patient is being seen for sequelae of PML due to natalizumab. The MS code would be listed third on the billing claim.
While visits with patients can be time-consuming, simple and definitive documentation can result in better reimbursement for services provided. In this era of ever-dwindling compensation to specialists providing such exacting and important care, please keep in mind that coding too little can lead to significant loss of reimbursement potential.
Previous issues of CONTINUUM have discussed using time spent in counseling and coordination of care as a basis for choosing Current Procedural Terminology (CPT) E/M codes for billing instead of the traditional “bullet method,”3,4 and also the use of prolonged service codes where appropriate.
For example, a patient comes to the clinic with a family member to discuss recent neurocognitive testing and the patient’s ability to work. Time spent was 32 minutes, which included discussion about the test results, job duties, and potential job modifications to allow the patient to continue working as well as the completion of forms for the patient to take to the employer. By documenting that “...the total time of the visit was 32 minutes (3:34–4:06PM), 23 minutes spent in counseling and coordination of care regarding test results, job duties, job modifications, and completion of employment forms...” it is appropriate to bill a level 99214 visit, whose “typical time” is 25 minutes.
Infusion services are an important aspect of MS treatment that are billed separately and based on whether the drug is purchased by the practice or by the patient, or sent from a specialty pharmacy. An excellent review has been recently published.5
Another area that a physician may need to code is management of an intrathecal baclofen pump. Such management includes not only refilling the pump but also provision or supply of drug and any reprogramming of the pump. Appropriate CPT codes for such services are noted below. These three codes are mutually exclusive and should not be reported together.
62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming
This includes interrogating the pump, evaluating the pump infusion rate, and any changes made to the infusion rate of drug. Notation should be made in the chart explaining the reason for the change, such as increased spasticity in the morning and the new settings. Always include a printout of the before and after settings.
95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed;
95991 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care professional
(Note that some payers deny claims if “other qualified health care professionals” do the filling, in spite of CPT official language.)
This includes the actual refilling of the pump, including accessing the pump by needle, withdrawal of any remaining baclofen solution, and installation of new volume of baclofen solution. This should be documented in the chart with a note that specifically mentions whether the procedure was performed by the physician or a nurse. Always include a printout of the before and after settings.
Additional codes that may be used include for the actual refilling of the pump and then reprogramming with new infusion or time settings. Codes 62367, 62368, and 62370 are mutually exclusive and should not be reported together.
62367 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir, alarm status, drug prescription status); without reprogramming or refill
62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir, alarm status, drug prescription status); with reprogramming and refill
62370 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir, alarm status, drug prescription status); with reprogramming and refill (requiring skill of a physician or other qualified healthcare professional)
J0475 is utilized to charge for the purchase and provision of the baclofen solution
A patient returns to the clinic for a baclofen pump refill. The patient reports worsening spasticity in the morning and several falls during the morning hours.
1. The nurse can refill the pump or have the pump reprogrammed by the physician (95990, 62368, J0475). If the physician separately evaluates the patient as an E/M (eg, for routine evaluation of other medications or side effects), then a 99214-25 can also be included; however, it is best to clearly state that this visit was separate from the time spent on the baclofen pump management.
2. The nurse defers the refill to the physician, who performs the refill and the reprogramming (95991, 62368, J0475). If the physician separately evaluates the patient as an E/M (eg, for routine evaluation of other medications or side effects), then a 99214-25 can also be included; however it is best to clearly state that this visit was separate from the time spent on the baclofen pump management.
Special thanks to Laura Powers, MD, FAAN for helpful comments and advice.