It is crucial to code accurately in the care of people with multiple sclerosis (MS) and other demyelinating diseases not only to ensure the financial health of the practice but also to provide better patient care. Knowledge of the various coding systems is essential. The International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) should be used for diagnosis- or problem-based coding.1 In addition to the diagnosis codes, Current Procedural Terminology (CPT) provides codes for Evaluation and Management (E/M) services as well as procedures done in the clinic.2
This article summarizes the relevant codes in ICD-10-CM, CPT codes for common and special procedures done in the clinic, and the issues associated with accurate documentation. A case vignette is included to illustrate these principles.
OFFICE VISIT DIAGNOSIS CODING STANDARDS
The first step to accurate billing for services rendered is to code the correct underlying diagnosis or diagnoses, which for most encounters with people for demyelinating disease is MS, the most common demyelinating disease of the central nervous system (CNS). In ICD-10-CM, the correct code is G35, Multiple sclerosis. If the patient has another demyelinating disease, the coding is more complex. For example, acute transverse myelitis is more specific, with subtypes based on etiology (eg, not otherwise specified [NOS], in conditions classified elsewhere, idiopathic). The increased specificity of ICD-10-CM is better represented by the expansion of several diagnoses in ICD-10-CM, including G36.1, Acute and subacute hemorrhagic leukoencephalitis [Hurst]; G37.2, Central pontine myelinolysis; and G37.4, Subacute necrotizing myelitis of central nervous system, which used to be captured by a single code in the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM), 341.8, Other demyelinating diseases of central nervous system.3
An encounter with a patient with MS or another demyelinating disease is not usually solely about addressing the diagnosis but also about evaluating and managing the symptoms, comorbidities, and complications of treatment. Thus, the second step in accurate coding is to include these with the appropriate codes because they are a part of medical decision making, contribute to overall risk, and more precisely represent the true level of disability. Too many potential symptoms and comorbidities exist for a comprehensive list, but Coding Table 1 includes some common symptoms and comorbidities and their respective ICD-10-CM codes. Some are simple direct transitions from previous editions of the ICD (eg, R30.0, Dysuria), but others demonstrate the increased detail in ICD-10-CM, including G82.2, Paraplegia, which includes subtypes based on whether the paraplegia is complete (G82.21, Paraplegia, complete) or not (G82.22, Paraplegia, incomplete). Many of the symptoms have complex variations based on clinical detail, and those listed in the table are only a sample.
OFFICE VISIT PROCEDURAL CODING
The most common procedure coded with CPT in clinic is the visit itself, E/M.4 This is based on the circumstances of the encounter, including whether it is the initial encounter or a subsequent encounter and whether or not it is a consultation (Coding Table 2). The principles of coding clinic encounters for E/M have been well covered in a previous issue of Continuum.5 One focus for patients with demyelinating disease is whether the code is based on medical decision making or on time spent on the encounter. Medical decision making is based on three factors: the number and acuity of problems, the amount of data reviewed or ordered, and the level of risk. Patients with demyelinating disease often have more than one active issue with moderate or high risk; therefore, coding all problems accurately is essential.
Additionally, many of these complex and highly disabling diagnoses require extensive counseling for patients and their families. If coding and billing are based on time, documentation of time spent on direct face-to-face counseling or care coordination is required, including documentation of what was done or what subjects were covered; this time must represent at least half the encounter. Sometimes counseling and care coordination are prolonged and go well past the maximum time captured by the basic E/M codes. If time spent is longer than 30 minutes, prolonged services codes may be used (Coding Table 2).
Beyond E/M, several procedures might be performed in the clinic. One of the most common is the diagnostic lumbar puncture (62270, Spinal puncture, lumbar, diagnostic). As applies to most procedures, one should be aware of the appropriate code modifiers. One example of a useful modifier is 53, Discontinued Procedure, which would apply to the rare aborted bedside lumbar puncture if the provider could not access the CSF. Also, if the lumbar puncture or other procedure is performed on the same day as the clinic encounter, the modifier 25, Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Professional on the Same Day of the Procedure or Other Service should be used with the E/M code.
More and more providers are offering infusion services in their clinics as a cost-effective alternative to hospitalization.6 Some complexity exists in the coding system for these procedures, including how long the infusion lasts, the type of substance or medication in the infusion, and the route of administration (Coding Table 2). It is important to note that the time represented in the code applies only to the infusion and does not include preparation.
Another complex procedure that is performed in the clinic is managing baclofen pumps for severe spasticity. Much of the coding depends on what is done, including electronic analysis of the pump with or without reprogramming and whether the medication is refilled or otherwise maintained. The correct code also depends on who is doing the work (ie, the physician or another provider).
DOCUMENTATION OF MULTIPLE SCLEROSIS AND NEUROIMMUNOLOGY ENCOUNTERS
Accurate coding helps inform appropriate billing but can only be done with the right documentation of services. As mentioned earlier, E/M has specific requirements for certain levels of coding and billing and is reviewed in detail elsewhere.4 As with any encounter, complete documentation should include all elements of the history and physical examination that was performed. For medical decision making, care should be taken in listing all problems or diagnoses that were addressed during the encounter, including not only the acute symptoms of the primary demyelinating diagnosis, but also the chronic symptoms requiring evaluation or management during the encounter. Any data (imaging, laboratory reports, pathology, and prior records) that were reviewed or ordered should also be listed. Knowing what features are included in risk calculation is important as well. For example, any encounter or problem addressed that requires IV infusion is considered high risk. If any procedure is provided on the same day as the clinic visit, the procedure and any time involved with it should be documented as separate from the main encounter. If counseling and care coordination are more than half the encounter, the exact amount of time spent on direct patient contact for counseling and care coordination should be documented.
This case illustrates the complexity of care for people with demyelinating disease and the resultant difficulty in coding accurately. Assuming complete documentation of the information presented in the case, the appropriate coding is summarized in Coding Table 3. This was a level 5 encounter because of the comprehensive history and physical examination and high level of medical decision making. The level of medical decision making can be determined by the two highest components; however, this case meets the highest standard of all three: extensive number of active new diagnoses or problems (cognitive disturbance, ataxia) and established diagnoses or problems (paraparesis, MS), data reviewed (independent review of MRI, summation of old medical records), and the high risk (IV therapy). Had documentation been lacking in the number of coded problems being addressed and in the review of data, then the highest billable code would be below the actual services rendered and would represent earned but potentially lost revenue. The documented time spent on counseling and patient care coordination was 25 minutes, more than half of a level 4 encounter (45 minutes) but not a level 5 encounter (60 minutes). Thus, it would not have qualified as a level 5 encounter without the comprehensive history and physical examination, even with the high level of medical decision making.
The procedures listed can be billed separately, provided they are done in addition to the appointment. The codes listed in Coding Table 3 indicate that someone other than the physician performed the interrogation, refill, and maintenance of the baclofen pump.
Telemedicine, also called telehealth, refers to the remote delivery of health care services using telecommunication technology. Telemedicine in neurology is rapidly evolving, in particular for use in acute stroke and neurocritical care. The Medicare telemedicine reimbursement policy was introduced in 1996 and substantially updated in 2000. Of importance is the adoption of telemedicine coverage into a state Medicaid plan and the mandating of telemedicine coverage for all (or most) commercial insurance carriers (the so-called “telemedicine parity legislation”). Most states (46, as of this writing) now cover some types of telemedicine services in their state Medicaid plans, and 22 states have passed some version of a commercial payer telemedicine parity law. The American Telemedicine Association reports that over 100 pieces of legislation that could affect telemedicine service delivery are currently being considered in state legislatures across the country. However, use of telemedicine by Medicare beneficiaries and providers has been far below original projections throughout its history.
The landscape of MS treatment has changed dramatically over the past decade. As of August 2015, 13 disease-modifying therapies for MS had been approved by the US Food and Drug Administration (FDA). Despite the availability of more treatment options, newer MS therapies often come with serious and even fatal adverse reactions. This often requires a well-coordinated and proactive approach from health care providers, resulting in additional visits and regular safety checks. The use of telemedicine in MS is a highly attractive strategy, not only to improve access to subspecialty expertise, but also for the management and even safety surveillance of patients receiving highly effective therapies.
Distant-site physicians and practitioners submit claims for telemedicine services using the appropriate CPT or Healthcare Common Procedure Coding System (HCPCS) code along with the modifier GT, via interactive audio and video telecommunication systems. Various services and corresponding CPT or HCPCS codes could be included in telemedicine visits (Coding Table 4).7
Caring for patients with demyelinating disease, including MS, is complex. It involves comprehensive care because of the myriad of symptoms, comorbidities, and treatment complications that can occur. The coding issues are likewise complex; proper coding should capture the extent of symptomatic treatment as well as the potentially complicated therapies and procedures that are becoming more common in the clinic setting.