Cohen, Bruce H. 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.
Current Procedural Terminology (CPT)1 contains the rules, codes, and definitions that describe the myriad of medical interactions and interventions that apply to the practice of caring for patients. These codes can be divided into Evaluation and Management (E/M) codes, which represent a small component of CPT and describe the cognitive services provided to patients, and procedural codes, which describe interventions such as injections, nerve conduction studies, and radiologic and surgical treatments. As cognitive specialists, most care given by neurologists who care for patients with muscle disease falls under E/M services, including office visits, hospital visits, and other direct face-to-face services that require no special technology, which will be the focus of this article. Many neuromuscular neurologists do also perform procedures that would include nerve conduction studies with electromyography or occasionally muscle biopsies.
A 43-year-old woman is referred by her primary care physician for a neurologic consultation to evaluate her weakness. She has a long-standing history of ptosis but has more recently reported diplopia, swallowing difficulties, and weakness. Her ptosis began as a teenager. On questioning about the onset of weakness, she offered that even as a child she was not able to climb out of a swimming pool using the metal sides of the pool. She describes the weakness in the past year as worsening as the day goes on. Her parents, three brothers, and two sisters are unaffected, and she has never tried to conceive a child. Her examination is normal aside from her relatively short stature (she is 5’0” tall and her parents were both taller than 5’6”) and a heart rate of 50 beats per minute. Her neurologic examination demonstrates a complete external ophthalmoplegia, retinal pigmentary changes, hypernasal speech, difficulty swallowing water quickly, and a mild proximal myopathy graded at 4+/5. Muscle stretch reflexes are absent, and she has a mild sensory ataxia. Based on the initial comprehensive history and examination, as well as discussion with the patient about the differential diagnosis and possible diagnostic approaches, the neurologist and the patient decide to start with an ECG to evaluate her bradycardia, and a simple genetic test (long-range PCR of the mitochondrial DNA) to support or refute the neurologist’s first diagnostic thought of Kearns-Sayre syndrome.
The choice of CPT code for this consultation would involve several factors. It is not likely that the neurologist would choose the counseling and coordination of care (time-based billing) for this visit, as most of the time would be spent obtaining a comprehensive history and performing a comprehensive physical examination. The discussion of diagnostic possibilities and methods of evaluation would include high-acuity diseases (including third-degree heart block, retinal degeneration, and progressive myopathy) as well as an invasive diagnostic evaluation (including nerve conduction studies/EMG, CSF examination, and a muscle biopsy). Therefore, a consult level 5 (CPT code 99245) would be reasonable for this patient. This patient would be unlikely to be covered by Medicare, based on her age, but because Centers for Medicare and Medicaid Services does not pay for consultation codes, the choice of a level 5 New Patient Visit (99205) would be appropriate, if she were covered by Medicare. The choice of diagnosis coding should reflect the primary diagnostic disorder, in this case Kearns-Sayre syndrome. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)2 codes should include 277.87 (Disorders of mitochondrial metabolism), and 378.72 (Progressive external ophthalmoplegia), as these best describe Kearns-Sayre syndrome. However, because an ECG will be ordered, the physician will want to include 427.89 (Bradycardia, other specified cardiac dysrhythmias), and 359.89 (Other myopathies). Other ICD-9-CM code choices are reasonable to include if other consults or procedures are requested, in order to support ordering these studies. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)3 code choices map out a bit differently. E88.40 is the proper code for Mitochondrial metabolism disorder, unspecified; however, H49.813 is defined as Kearns-Sayre syndrome, bilateral. In this case, choosing both codes is reasonable. Finally, G72.89 (Other specified myopathies), should also be considered. As one goes through the process of choosing codes, it quickly becomes apparent that there is no exact mapping of ICD-9-CM to ICD-10-CM for some neurologic codes.
A 53-year-old man is seen 2 weeks after a surgeon performed a muscle biopsy, for the purpose of discussing the results of the biopsy and treatment options. His initial neurologic visit was 3 weeks ago, at which time he presented with a 3-year course of mild but progressive bilateral leg weakness, difficulty swallowing, and three recent creatine kinase (CK)-MM levels of 550 to 700 U/L (normal 80 to 220 U/L). He has never been on a statin medication. A comprehensive examination at that initial visit revealed 4+/5 weakness in his legs and proximal arms, without other findings. At that initial visit, the neurologist ordered a thyroid battery, erythrocyte sedimentation rate (ESR), rheumatoid panel, acid maltase enzyme assay, and paraneoplastic panel, which were normal, and therefore a biopsy was ordered. In a 30-minute phone call between visits, the neurologist explained to the patient the results of the laboratory tests, and the differential diagnosis being inclusion body myositis and polymyositis. At the return visit, the patient reports that his symptoms have not changed. The biopsy report is not conclusive for any definitive diagnosis but shows some minor perivascular inflammatory changes that the pathologist did not feel were diagnostic of polymyositis. The neurologist discusses these results with the patient, suggests a trial of prednisone (which may be helpful in polymyositis and not helpful in inclusion body myositis), and discusses the concern that despite the normal paraneoplastic panel, an occult neoplasm is still a consideration. The neurologist and patient decide on a trial of prednisone, and the neurologist orders a chest CT and colonoscopy. The discussion lasts a total of 30 minutes.
This was an established patient visit. The time spent on this case between visits, including the prolonged phone call, are not relevant for choosing a billing code for this visit. There are CPT codes for telephone calls, but insurance companies do not reimburse these encounters. During the visit, the neurologist collected very little new data-only that the symptoms were unchanged. The neurologist did not perform any physical examination other than what was observed while sitting and talking with the patient. Medical decision making in this case was highly complex because the number of diagnostic and management options was extensive, the data complexity integrated by the neurologist at the time of the visit (including the laboratory tests ordered at the time of the initial visit) was extensive, and the risk of morbidity and mortality was high. The course of therapy, prednisone, has a high risk of morbidity, even if effective. The neurologist ordered additional laboratory testing that was invasive and will require contrast dye and sedation to complete. Established patient visits require only two out of three core elements (history, examination, and medical decision making) in order to complete the coding requirements. Using the bullet method of billing, it would be difficult to bill beyond a level 2 (99212) because the neurologist did not perform (or need to perform) anything beyond a problem-focused history and physical examination. To bill a level 4 (or 5), the neurologist would have had to perform a detailed (or comprehensive) history or examination. In this case, there was no need to perform such an evaluation. Despite the very complex medical decision making, using the bullet method of coding, this only rises to a 99212 visit. However, using the counseling and coordination of care–based method, a visit lasting between 25 and 39 minutes, in which more than one-half of the time was spent with counseling or coordinating care, can be billed as a 99214. If the physician spends 40 minutes with the patient, a 99215 code can be used.
This case underscores the need for the clinician to be aware of the nuances of both methods of coding, as well as to understand that any time spent between visits or without the patient in the examination room will not be reimbursed. These issues are common in the practice of a neurologist who cares for patients with neuromuscular problems. The proper ICD-9-CM code for the working diagnosis (polymyositis) is 710.4, and the ICD-10-CM code is M33.2 (Polymyositis, organ involvement unspecified). The proper ICD-9-CM code for inclusion body myositis is 359.71, which directly converts to G72.41 in ICD-10-CM.
A 30-year-old woman with recently diagnosed myasthenia gravis calls her neurologist’s office to say she has a runny nose and is feeling a bit weaker. The neurologist had diagnosed her 2 weeks ago based on clinical symptoms, an EMG, and a positive antibody test, and had started pyridostigmine bromide. Her chest CT at that time was normal, and she has not yet seen the surgeon for consideration of a thymectomy. The nurse who answered the phone tells the patient to come into the office, and the neurologist quickly surmises that she has a simple upper respiratory infection but is clearly weaker than she was 2 weeks ago. The neurologist calls the intensive care unit (ICU) to arrange for a direct admission to the ICU, on the medical ICU’s service (not the neurologist’s service). The total duration of this encounter was 20 minutes, with almost all of the time spent coordinating care, and the neurologist is not the admitting doctor, so the correct choice of CPT code is 99213, because the neurologist performed almost no history and examination. (Neither the complexity of the case nor the correct decision to admit her to the ICU counts toward the appropriate CPT code selection in this case). The next morning, the neurologist stops by to see the patient in the ICU. The ICU attending reports that her respiratory parameters were stable for most of the night but that she now seems more anxious and her tidal volumes and inspiratory pressures are lower. The team had tried noninvasive respiratory pressure support (bilevel positive airway pressure [BiPAP]), but this made the patient more anxious, so it was discontinued. The neurologist talks with the patient to see how she is feeling and performs a comprehensive examination, including a full mental status examination because of the new anxiety, then spends some time discussing the case with the respiratory therapist who has been caring for her for the past 8 hours and the ICU attending physician. Together, they decide that an elective intubation is reasonable, and the neurologist then discusses this decision with the patient and her parents. The total time the neurologist has spent on this patient’s care in the ICU is 75 minutes, none of which was spent performing any teaching duties.
Because this patient was admitted as a primary patient to the ICU staff, a new patient code cannot be used. This is also not a consultation, as the neurologist had seen the patient and arranged for her admission. The proper code selection would be a subsequent care visit code, but because of the additional time spent in the ICU (although that time was not spent performing ICU duties), an inpatient extended time code can be used. A 99233 code (a level 3 subsequent care code is the highest level) is appropriate because the neurologist exceeded the requirement for a detailed examination and the level of medical decision making is high. When choosing to use an additional code for time, the neurologist must refer to the typical time required for the base code; in this case, the typical time for a 99233 is 35 minutes. The codes for in-patient additional time are 99356 (for an extra 30 to 74 minutes beyond the base time code) and 99357 (to be used with 99356 for each additional 30 minutes beyond the 74 minutes, with the ability to use multiple units of 99357 if needed). In this case, the neurologist spent a total of 75 minutes at the bedside and on the patient’s hospital floor or unit. Subtracting the base time of 35 minutes, the neurologist spent an additional 40 minutes, which exceeds the minimum of 30 minutes needed to submit a 99356 code. Therefore, it would be proper to submit both the 99233 and 99356 codes. If the neurologist makes repeated visits to the patient during the day because of medical necessity, he or she can calculate (and document) the total daily floor time, then calculate and submit the proper additional time codes. It is important to note that the neurologist’s medical care does not qualify as critical care E/M codes. The rules for using the critical care codes go beyond the scope of this article but can be found in the CPT manual. Additional time codes are available with the same time requirements for outpatients (99354 and 99355). In this case, the best ICD-9-CM code is 358.01 (Myasthenia gravis with acute exacerbation), which falls in the Myoneural Disorders grouping and converts directly to G70.01 in ICD-10-CM, with the same descriptor falling in the Myasthenia Gravis and Other Myoneural Disorders grouping.
SUMMARY AND CONCLUSION
The cognitive effort of the practice of neuromuscular neurology is not dissimilar to the practice of general neurology or most other subspecialties within neurology. Therefore, it is important to understand the rules that apply within the Evaluation and Management chapter of the CPT book. This chapter comprises two chapters (44 pages) of the 912-page 2013 edition. The nature of neurology practice lends itself to face-to-face discussions that involve patient education or coordination of medical care, and therefore it is sometimes more appropriate to bill for physician time in the context of the office visit or bedside visit, as opposed to making sure enough bullet points are covered and documented. Extended visits in the office or hospital setting may not be a day-to-day occurrence, but when they do occur, it is appropriate to bill for that time. The nomenclature within ICD-9-CM and ICD-10-CM for most of the nerve and muscle disorders is straightforward, but not all codes are within the Neurology chapter, nor does ICD-9-CM always map directly to the same code in ICD-10-CM.