Yerby, Mark S. MD, MPH, FAAN; Powers, Laura B. 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.
The evaluation and management of epilepsy during pregnancy is complex, requiring coordinated care between the neurologist and obstetrician.1,2 Given the complexity of these conditions, the American Academy of Neurology has developed guidelines to assist neurologists in developing comprehensive plans for such patients. The potential for liability is significant when managing women with epilepsy immediately before and during pregnancy; therefore, the following issues will need to be covered in the medical record.
* Education of the patient with a clear statement of the risks of seizures and antiepileptic medication, and the use of folic acid.
* Education of the obstetrician with review of the risks, one’s plans to mitigate them, and a plan for the obstetrician to treat acute maternal seizures during labor and delivery.
* Verification of the diagnosis of epilepsy. Not all seizures are epilepsy, and one needs to be able to support the diagnosis.
* Considerations of alternative treatments from among the various antiepileptic drugs (AEDs).
* Consideration of comorbidities (women with epilepsy have higher than expected rates of depression, anxiety, and migraine, as well as eclampsia).
* Determination of the most effective AED and plasma concentration range for an individual patient.
* Development of a plan for monitoring AED levels during pregnancy and the postpartum period.
* Development of a plan for treating acute seizures.
* Development of a plan for postpartum management.
PROPER EVALUATION AND MANAGEMENT CODING
Epilepsy patients, particularly when pregnant, require a level of complexity and extra time spent in their care that qualifies them for higher levels of medical decision making and increased levels of service. This is also true for patients with other neurologic diseases affecting or affected by the pregnancy. The documentation for the level of service must meet Current Procedural Terminology (CPT) requirements for the “bullet” method, be based on time, or make use of prolonged service codes as discussed in previous issues of CONTINUUM.3
The Official Guidelines for Coding and Reporting for both International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) have special sequencing instructions for coding of patient visits during pregnancy.4,5 A code designating the pregnancy is always listed first unless the condition for which the patient is being evaluated has no effect on the pregnancy or is not affected by the pregnancy in any way. Both classifications have codes specifically created for use with neurologic conditions complicating or affected by pregnancy.
ICD-9-CM Codes Used in Visits for Patients With Neurologic Conditions
(In the following table, x is a placeholder for the fifth digit, to be coded as follows: 0 = unspecified as to episode of care or not applicable; 1 = delivered, with or without mention of antepartum condition; 2 = delivered, with mention of postpartum complication; 3 = antepartum condition or complication; 4 = postpartum condition or complication.)
642.6x Eclampsia with convulsions
646.4x Peripheral neuritis in pregnancy
646.8x Other specified complications of pregnancy
Use for nonepilepsy conditions and add a code for the condition
649.4x Epilepsy complicating pregnancy, childbirth, or the puerperium
Use additional code to identify the specific type of epilepsy
Excludes: eclampsia (642.6x)
671.5x Other phlebitis or thrombosis, cerebral venous sinus thrombosis
674.0x Cerebrovascular disorders in the puerperium
Any condition classifiable to 430-434, 436-437 occurring during pregnancy, childbirth, or the puerperium or specified as puerperal
V26.49 Other procreative management counseling and advice
V22.2 Pregnant state, incidental
Code this following the neurologic condition code when the condition is not affected by or does not affect the pregnancy
ICD-10-CM will be used for diagnosis coding in the United States beginning October 1, 2014. In ICD-10-CM, the trimester and delivery status is captured in codes, but not always at the same character position.
ICD-10-CM Codes Used in Visits for Patients With Neurologic Conditions
Note that the codes from the ICD-10-CM chapter on pregnancy begin with the letter “O”
O15.00 Eclampsia in pregnancy, unspecified trimester
O15.02 Eclampsia in pregnancy, second trimester
O15.03 Eclampsia in pregnancy, third trimester
O15.1 Eclampsia in labor
O15.2 Eclampsia in the puerperium
O15.9 Eclampsia, unspecified as to time period; Eclampsia, not otherwise specified
O22.50 Cerebral venous thrombosis in pregnancy, unspecified trimester
O22.51 Cerebral venous thrombosis in pregnancy, first trimester
O22.52 Cerebral venous thrombosis in pregnancy, second trimester
O22.53 Cerebral venous thrombosis in pregnancy, third trimester
O26.821 Pregnancy related peripheral neuritis, first trimester
O26.822 Pregnancy related peripheral neuritis, second trimester
O26.823 Pregnancy related peripheral neuritis, third trimester
O26.829 Pregnancy related peripheral neuritis, unspecified trimester
O87.3 Cerebral venous thrombosis in the puerperium
O99.350 Diseases of the central nervous system complicating pregnancy, unspecified trimester
O99.351 Diseases of the central nervous system complicating pregnancy, first trimester
O99.352 Diseases of the central nervous system complicating pregnancy, second trimester
O99.353 Diseases of the central nervous system complicating pregnancy, third trimester
O99.354 Diseases of the central nervous system complicating childbirth
O99.355 Diseases of the central nervous system complicating the puerperium
O99.411 Diseases of the circulatory system complicating pregnancy, first trimester
(These codes are used for cerebrovascular disease)
O99.412 Diseases of the circulatory system complicating pregnancy, second trimester
O99.413 Diseases of the circulatory system complicating pregnancy, third trimester
O99.419 Diseases of the circulatory system complicating pregnancy, unspecified trimester
O99.42 Diseases of the circulatory system complicating childbirth
O99.43 Diseases of the circulatory system complicating the puerperium
Z31.69 Encounter for other general counseling and advice on procreation
Z33.1 Pregnant state, incidental
Coding Case 1
A 24-year-old woman with a history of localization-related epilepsy and rare secondary generalization controlled on levetiracetam, came for consultation (requested by her internist) and advice on whether she should remain on or change her medication, since she had recently married and was planning to have children. She did not currently have an obstetrician.
After confirming her diagnosis, the neurologist reviewed the risks of pregnancy and epilepsy in terms of both maternal seizures and antiepileptic medication–related risk to the fetus. The neurologist also discussed ways to minimize risks and plans for monitoring her levetiracetam during pregnancy and the postpartum period, as well as for acute seizure management, and reviewed the information on breast-feeding. This visit took an hour. The documentation met criteria for comprehensive history and physical exam.
The CPT Evaluation and Management code appropriate for this visit, given the high level of medical complexity, would be 99245 if the patient’s insurance or other payer allows use of consult codes. If not, then the new-patient code 99205 is appropriate. Prolonged service codes are not appropriate here because the “typical time” for 99245 is 80 minutes and for 99205 is 60 minutes. Prolonged service must be at least 30 minutes beyond the “typical time” for a visit code. The ICD-9-CM codes would be 345.40 (Localization-related epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy) and V26.49 (Other procreative management counseling and advice). The corresponding ICD-10-CM codes for use after October 1, 2014, are G40.209 (Localization-related epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus) and Z31.69 (Encounter for other general counseling and advice on procreation).
Coding Case 2
A 28-year-old pregnant woman with epilepsy was admitted to the hospital for non-neurologic complications of the second trimester of her pregnancy. She had a seizure while hospitalized, and a neurologist who had not seen her before was asked to consult. Her epilepsy had previously been well controlled. After determining that she did not have eclampsia, the neurologist established her epilepsy type as complex partial with secondary generalization, evaluated her anticonvulsant medication, and made dose adjustments. The neurologist then counseled the patient and her family about seizures in pregnancy, effects of the seizure and medications on her fetus, and developed a treatment plan for managing potential acute seizures during the remainder of her pregnancy. The documentation met criteria for a detailed history and physical examination. The visit took 85 minutes, and 55 minutes were spent in counseling and coordination of care (times documented).
Although the history and physical examination did not fulfill the requirements for a level five consultation (99245) or new patient (99205), the time spent in counseling and coordination of care does. The ICD-9-CM codes would be 649.43 (Epilepsy complicating pregnancy, childbirth, or the puerperium) and 345.40 (Localization-related epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy). The ICD-10-CM codes will be O99.352 (Diseases of the central nervous system complicating pregnancy, second trimester) and G40.209 (Localization-related epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus).
Let us say, for example, that the neurologist in this case did determine that the patient’s recent seizure was due to eclampsia. The first-listed ICD-9-CM code would be 642.63 (Eclampsia, antepartum condition or complication). In ICD-10-CM, the first-listed code would be O15.02 (Eclampsia in pregnancy, second trimester). The epilepsy code would be listed secondarily, as this condition would also be necessarily addressed.