Grand Rounds-Principles of CPT Coding for Cranial Procedures and E&M Coding

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- Thank you for joining us for a second session of CPT coding. This session will be dedicated to cranial procedures. We're lucky to have with us, Kim Pollock from KarenZupko, and Director of Spine Surgery, Joe Chang from Vanderbilt University. Kim and Joe, do not have any conflicts of interest to report. And we really do appreciate their time for this very valuable topic. Please take it away.

- Great. Thanks Dr. Cohen. Dr. Chang?

- Thanks Aaron. It's a pleasure. Like I said, except for the first part, this is gonna be an incredible session going over craniotomy procedures and non spine coding with cranial procedures. Certainly, I'm really proud of the relationship that we've had with WNS and KZA, as far as creating coding courses, coupling consultant coders, along with positions to get you the best and really the largest breadth of understanding these coding principles. With that, I'll have it back to Kim.

- Thanks Dr. Chang. And welcome to the second half of the coding webinar, focused on cranial and non spine procedures. We've already discussed the what's included in the global surgical package and using modifiers to optimize your revenue. So if you haven't listened to that portion of the spine webinar, you might want to do so. To be up to date with where we're going from here on now. So when it comes to coding craniotomy procedures, it's usually a lot more simple than coding spine procedures. There is typically just one primary craniotomy code and the craniotomy codes are diagnosis driven. For example, we have two craniotomy for tumor codes. And we even have more specific craniotomy for acoustic neuroma codes or meningioma. We have craniotomy for aneurysm codes, craniotomy for subdural hematoma, pituitary tumor codes. So that primary procedure code, that standalone code, pretty much describes the entire operation from start to finish, skin to skin. There are some additional codes that we can think about using. The first one is the operating microscope, 69990. Now this code, the use of the operating microscope from microdissection, can be billed with all of the craniotomy codes when it's appropriate with the exception of 61548, the transsphenoidal hypophysectomy code or transnasal, transsphenoidal removal of a pituitary tumor code, includes the microscope. So we would not separately bill, 69990. Then we can also look at reporting using stereotactic navigation when performed. And I discussed in the earlier webinar, the requirements for what needs to be documented when billing these codes. But the 61781 is for, when you do stereotactic navigation to resect an intradural tumor, and 61782 would be for extradural procedure. Now the stereotactic navigation is included in our CPT codes where the word stereotactic is included in the code. For example, stereotactic brain biopsy and stereotactic placement of deep brain stimulator electrodes. So we would not separately bill 61781, 61782 with those codes. Additionally, we can also think about reporting, placing a ventricular catheter through a separate hole. 61107 is for the twist drill hole, ventricular catheter placement, 61210. If that ventric is placed through a burr hole, and then we can separately bill for placing a lumbar drain, harvest of graph material through a separate skin incision, abdominal fat, 20926, fascia lata 20920 to 20922. If you have an intraoperative MRI and iMRI suite, there are codes that in the radiology section of CPT, that the neurosurgeon may separately report. Now, some institutions have a rule though that only the radiologists can build those. So you want to double check with your institution. But otherwise, any other intraoperative imaging like ultrasound is included and not separately reported. And then typically, the last item that we think about billing would be placement of brain intracavitary chemotherapy agent, like gliadel wafer. And we have an add on code for that, 61510. And that code is reported once with a tumor code, 61510 or 61518, is built once regardless of the number of wafers placed. So a couple of the main state codes that we have in our craniotomy for tumor procedures for our supratentorial procedures, 61510, encompasses our brain tumors, metastatic brain tumors, primary brain glioblastomas. 61512 is specific for meningioma, and 61516 would be for some kind of cyst, like an arachnoid cyst. The infratentorial codes equivalent, 61518, 61519 for meningiomas, and 61524 for a cyst. Now the CP angle tumors like acoustics and pituitary tumors, have their own codes that we'll talk about in just a little bit. And again, other potentially billable codes would be stereotactic navigation, placing the intracavitary chemotherapy agent using the operating microscope, and a ventricular catheter. That then, remember that ventricular catheter needs to be placed through a separate burr hole or twist rail hall, not through the same surgical exposure. So an example here is a craniotomy for resection of a left temporal glioblastoma with stereotactic navigation, the microscope, and cranioplasty. We've got the primary procedure code of 61510, stereotactic navigation for the intradural resection. And then the microscope, 69990. Now this code 69990 has modifier 59 appended to it. And that was new. Excuse me. As of last year, because Medicare developed a what we call a correct coding initiative edit. So they've developed an bundling edit that bundles, or includes the microscope in with the stereotactic navigation. Unless, you add modifier 59 to say that this was completely separate. So remember to add modifier 59 to the microscope code, when you bill it with the navigation code. Now, in this example, there was a quote cranioplasty with plate and screws. Remember, any time you replaced the bone flap that you lifted, that's not separately billable. That's considered closing the operative track, and it's not a separate cranioplasty code. Another example for resection of a meningioma and intraoperative ultrasound, placement of cranial tongues, the microscope, repairing the dural, and the cranioplasty to reaffix the bone flap. And again, oh, sorry, there's a wrong code on there. It should be 61512. So the 61512 would be your craniotomy from meningioma, and 69990, use of the operating microscope. All of the other activities, the ultrasound is included, placement of cranial tongs is included, repairing the dura is included. You had to open the dura to resect the meningioma, and then the cranioplasty to reaffix the bone flap is included and not separately billable.

- Kim, one thing I'd just wanna say, is that you're right. The difference between the craniotomy for tumor codes versus craniotomy meningioma codes, historically, came from the fact that the meningioma or the meningioma codes, actual valued higher due to the fact that the resection of the tumor actually, requires you to take out the whole thing, versus typically in the past where glioma, even though you may save, you've got a gross total resection that may or may not have been complete. And so this, that's one of the reasons why the meningeal codes are valued higher than the equip, just the other neoplasms.

- Good point. The next set of tumor codes is for acoustic neuromas or cerebellopontine angle tumor codes, We have two primary procedure code. 61520 for that suboccipital or retrosigmoid approach. And then 61526 for the transtemporal or trans labyrinthine approach for the removal. Now typically, the neurosurgeon and neurotologists would do these procedures together, so that both surgeons would build the same single CPT code. For example, 61520 with modifier 62. It's not appropriate to use skull based codes for the excision of these, the suboccipital or retrosigmoid or translabyrinthine approach for removal of an acoustic neuroma. The skull base surgery codes were developed in 1994. And we've been removing acoustic neuromas long before 1994. These codes have been in existence for a long time to describe these procedures. And that's another area where we oftentimes, see misuse of the code. So other potential codes would be harvesting an abdominal fat graft to help with the closure because it's sort of separate skin incision. We can bill that, 20926. Use the operating microscope, 69990. Stereotactic navigation, if done, 61781. Again, if you placed a ventricular catheter through a separate burr hole, 61210, or spinal drain, 62272, can be separately bill. And so the example in this case is a suboccipital craniectomy with a subtotal removal. Dr. Otologist did the decompression of the internal auditory canal, which is included in the primary procedure code and not separately billable for the otologist. Cranioplasty closure, intraoperative monitoring, placement of the drain, and the microscope. And so this is an example of where we use the co-surgery modifier, 61520-62. Both surgeons would build that, the microscope. The neurosurgeon would bill for the lumbar drain, the decompression of the IAC is included in the primary procedure code. The cranioplasty is included. And so as the intraoperative monitoring. Pituitary tumor removal, there are three codes to describe that. 61548 for the transnasal or the transseptal approach. 61546 for the craniotomy approach. And then 62165 for the endoscopic approach, so using the endoscope. And again, the approaches included in all of these codes. So if ENT does the approach, then each surgeon would build the same CPT code with modifier 62. And you can separately bill for the stereotactic navigation, placing the lumbar drain or the abdominal fat graft as appropriate. And remember the microscope, 69990 is included in 61548. So here's an example of a transnasal transsphenoidal removal of a pituitary tumor and an abdominal fat graft. So if you do the procedure yourself, you would build a code 61548, without a modifier. And the fat graft is 20926. And if ENT did the approach, then you are sharing the primary procedure code of 61548, each bills, the same code with modifier 62. And then you would bill for the abdominal fat graft. The ENT would not separately bill for septoplasty and endoscopic sinus surgery. The skull base surgery codes as I mentioned previously, were introduced into CPT in 1994, to address procedures that were being perf- when new procedures being performed to address tumors at the base of the skull and the codes were designed, so that multi-disciplinary parties could participate in the case and have their own codes. So we have approach codes for anterior fossa tumors, middle fossa tumors, and posterior fossa tumors. And then we have the tumor resection codes that are paired with the vital locations, anterior fossa, middle fossa, and posterior fossa. Now the definitive procedure or the tumor resection codes actually are split up into two types, extradural tumor resection and intradural tumor resection. So the intradural tumor resection codes again, include repairing the dura because the concept is, if the code says intradural then it implies that you've opened the dura, and you're supposed to close it as well. So we would not separately bill a dural code with these definitive procedure codes. So these codes are designed to be used as paired codes. So if you or somebody else, like ENT is using the approach code, it's likely then that you would use the matching or correlating definitive procedure code. The point is not to mix and match codes. And I've seen people misuse these codes by billing a skull base approach code with a usual craniotomy code. And what that does really is, you are double dipping on the approach, which would not be appropriate. Right now, these codes, we do not have a separate codes for endoscopic skull base procedures, except for the pituitary tumor removal code of 62165. So the usual skull base codes is listed at the top of the slide, are for open procedures. So if you're doing an endoscopic, endonasal skull base surgery, other than on the pituitary tumor, then we have to use an unlisted code, the 64999 code for that. This next slide just illustrates again how the skull base codes have separate approach codes, and the approach codes include the access to the skull base. And then the definitive procedure or the resection code would include the resection and dural closure rather than the standalone craniotomy codes, which include the approach, the resection, and the closure. The first example, if an ENT does the transpetrosal approach to the posterior fossa and the neurosurgeon then removes the intradural meningioma. ENT would bill the approach code, neurosurgery would build the definitive procedure codes. So each person really has their own codes to report. If you're the neurosurgeon, did the exposure and remove the tumor then you would build both codes. And if it's an endoscopic resection of a non pituitary tumor, then again, we're using the unlisted code 64999 for that. The skull base surgery codes have a secondary repair of the dura or the surgical defect of the skull base codes, 61618 and 61619. But CPT terminology, secondary repair means that a different operative session. And again, the resection codes, the intradural resection codes includes the repair of the dura. So we would not separately bill 61618 or 61619, unless we were taking the patient back to the operating room to repair a leak. The next set of codes, craniotomy for aneurysm codes. We have four codes, 61697 and 61698 for complex aneurysms, and 61700 and 61702 for quote, simple aneurysms. Now, if you ask me, all aneurysms are complex. But I'm not a neurosurgeon. So when we look at the CPT definition of what simple versus complex is, complex is anything that's greater than 15 millimeters in size. So you have to document the size. You cannot just say giant aneurysm or there's calcification at the aneurysm neck, or the aneurism incorporates normal vessels into it, or there is a temporary vessel occlusion. So you tempt apply it, place a temporary clip. If it doesn't meet any one of those criteria, then it's considered simple. So these are the important points of documentation for use of the complex aneurysm codes. Now these codes include the removal of any hematoma associated with a ruptured aneurysm. So you would not separately bill a craniotomy for hematoma code. So these codes include clipping a ruptured versus unruptured aneurysm. It doesn't matter. If you have to expose the carotid artery for potential control then we could. Because it's a separate incision, we can build the 35701. If you are injecting dye for like ICG, indocyanine green dye or flouricine. That's not separately billable for the neurosurgeon, but you can separately build a microscope, a ventricular catheter placed or a separate burr hole, a lumbar drain. And then in the postoperative period, something to remember is that, if the patient subsequently develops hydrocephalus, and you have to take the patient back to the operating room for a ventricular catheter, or even a VP shunt, the 62223, we can build that with modifier 79. Okay. Modifier 79 as we discussed earlier, because it's a different diagnosis. And it's not a complication of the aneurysm surgery. It may be a complication of the disease process, but it's not a complication of the procedure. So therefore, modifier 78 is not appropriate. So a couple of examples here. Number one, clipping of ruptured aneurysm of the right ACom, using the operating microscope. Example number one is clipping a ruptured right ACom aneurysm with use of the operating microscope. And the code is 61700, and the microscope, 69990. And then example number two is a frontal craniotomy with taking down of the clinoid process, flattening the sphenoid wing with use of a- clipping the aneurysm with use of a temporary clip. And the temporary clip is what justifies the complex aneurysm code. Now the cranioplasty in the defect of the sphenoid wing is not separately billable. That is just part of your closure. So we would not separately bill a cranioplasty code for that. Craniotomy for AVMs, the AVM codes are determined by the location of the AVM, super tentorial, infratentorial or dural, and the type, simple versus complex. And again, if I think they're all complex and unfortunately, there is no CPT definition of simple versus complex. So we use the Spetzler-Martin scale to determine whether it's simple or complex. So just be sure you document the size of the nidus, document to, whether it's in that eloquent area of the brain, or if there's a, what the venous drainage is. Dr. Chang, do you want to jump in here on this one?

- Yeah, I do. Just so we want to clarify this definitions through CPT for both aneurysms and AVMs, between simple and complex, really due to the risk of neurologic deficits in the patient. So for example, Spetzler-Martin grade, AVMs of three or higher, certainly have a much higher risk factor than those of a one or two. And that's the same thing for aneurysms. That if you notice the criteria, is really based on the risk of a neurologic injury for our patients. But that kind of adds a little bit clarity of trying to define simple and complex.

- Good point. Thank you. The Chiari malformation code, 61343, is another one that's oftentimes misused. This code says craniectomy, suboccipital with cervical laminectomy for decompression of the medulla and spinal cord with or without dural graph. And so the code includes the craniotomy, the laminectomies, the decompression, the dural repair, and the closure. So basically, it's a one code describes the entire procedure. You can separately bill from the microscope, ventricular catheters, stereotactic navigation, if performed. Decompressive craniotomy codes for treatment of intracranial hypertension were new a couple of years ago. And these codes are 61322 for the decompressive craniectomy without lobectomy, 61323 with lobectomy. And then if you actually make an incision in the abdomen and place the bone flat in the abdomen for storage until the brain swelling heals, then we can add on 61316 to the craniectomy codes. you can also add it onto craniotomy for subdural. Sometimes, you do a decompressive craniectomy procedure for subdural hematoma. So we would build a subdural hematoma craniotomy code and the storage, the 61316 code, If you store the bone flap in the abdomen. Now when you go back to put the bone flap back on six weeks, eight weeks, whenever, later. Then we call that a 62143, that cranioplasty procedure is really replacing the bone flap, the patient's bone flap. And if you have stored the bone flap in the abdomen, we can also build 62148 for incision and retrieval of the subcutaneous bone flap for cranioplasty. If the bone, if you're not using the bone flap, and you have to reconstruct using methacoline or something else, then the regular cranioplasty code, 62140, 62141 would apply. If you do that replacement of the bone flap or cranioplasty procedure within the global period of the initial procedure, then we would add modifier 58 to that second procedure to show that this was a prospectively planned reconstruction. And so the example here, is that you've got a 19 year old female who had a traumatic brain injury, who was in an MVA and you did a right decompressive hemicraniectomy and placement of bone graft in the subcutaneous abdominal pocket. So 61322 and 60316. And then several weeks later, the patient presents for reconstructive cranioplasty with the retrieved bone flap. So we have the code 62143 modifier 58 because we're in the global period of the first procedure. We're in the 90 day global period. And then the 62148 for the incision and retrieval. The intracranial hematoma removal codes vary depending on the approach and then the location of the hematoma. So we have a twist drill hole procedure approach for an extra dural or subdural hematomas, 61108. The burr hole, 611544. For subdural, 61156 for intracerebral. Notice that these codes say hole or holes, plural. So that means any number of holes on that same side and these codes we can use modifier 50 with, if we do a burr holes or twist drill holes on either side of the midline. And then super tentorial craniotomy, 61312. For extradural, subdural, 61313, for intracerebral. And then the infratentorial codes, 61314 and 61315. And again, these codes have a 90 day global period. So if, for example, on the day one, you did burr hole drainage via two left burr holes for chronic temporal subdural, we would use 61154. And then if we had that, if a couple of days later, that chronic subdural recurred, and we did a more extensive procedure, a craniotomy, we would build a 61312 with modifier 58 for staged or anticipated procedure. And we would be reimbursed a hundred percent of it allowable for this code. We would not use modifier 78 for complications. Then we have the ventricular peritoneal shunt codes. The 622234 for a creation of the VP shunt, which includes your initial programming. So we would not separately report 62252, which is your reprogramming of a programmable shunt code. If the general surgeon did the peritoneal portion of the shunt, then you both would build 62223 with modifier 62 for co-surgery. Replacement or revision of the shunt components, the 62225 for the replacement or irrigation of the ventricular catheter, is the first code. And then the second code is 62230 for replacement or revision of the valve or the distal catheter. So one code for the valve or the distal catheter. If you revise both components, we can bill for both codes. But if you just removed the entire system, then we would build 62256. And if you removed and replaced at the same operative session, it would be 62258, a single code. And again, the reprogramming code is 62252. So the insertion or the placement of the VP shunt code, 63223, includes the initial programming, but any reprogramming that you might do in the hospital or in your office later on, even in the global period, can be separately billed with 62252. You might need modifier 58 on it for planned or anticipated, if you're in the global period. And then lastly, neurointerventional coding, while not commonly performed by neurosurgeons, is very complicated. And I wanted to just point out here, that it's the component codes. There are five different component types of codes that we can build. The coding is very complicated. And I would urge you to attend the AANS course to learn more about that, or to ask us, KZA, for some additional help learning this, because it's not something that you can teach in 15 minutes. Dr. Chang, anything else you'd like to add about cranial procedure coding?

- Okay, I think you did a great job. As you noted some of these codes have their own set of rules. Like you've kind noticed with the skull base codes, how they're less related to diagnosis versus location. So you would use certainly, what are the definitive codes based on location for neoplasm, infection, vascular, et cetera, while others do require the diagnosis driven. So I think it's important the differences between the two. And as you said, the vascular coding is really complex. That's gonna give and get more complex next year, as there are some bundling that has to occur due to the reporting of the radiology S and I components versus the procedures itself, some concerns about doing the angio one day or the angio relative to the definitive procedure. So not only attending the WMS cope, I think your company actually has some products that can help people sort this out. And one of the things when it comes to component coatings is without understanding all the parts of it, you can end up inadvertently, leaving a lot of money on the table.

- Yes, exactly. Exactly. Okay, great. So the last section of this webinar is to talk about the non-surgical services you bill. And in a typical neurosurgery practice, this can account for up to 10 to 20% of your total practice revenue. So it's really nothing to sneeze at. But just a reminder, that these codes are used by physicians across all specialties. So there are very defined guidelines for using these codes, which is why they are on the audit list of most of the payers, including Medicare. Right now, the Office of the Inspector General has no fewer than four audit initiatives, addressed at E and M codes. So the neurosurgeon said to me, oh, I don't make much money on my E and M codes. I'm either not gonna build them at all or I'm just gonna always build low levels of codes. And I think if you really look at the details of your revenue, you would find that your E and M code can play a significant role in your practice revenue. So we want to understand the rules for the coding. And again, we spend a lot more time talking about E and M coding in the AANS course. Because this again, I'm not gonna do it much justice with this overview, but it will give you a taste of the E and M codes. So the E and M codes are five digit CPT codes. And the fourth digit is what we call the category of code. And this number changes depending on the location of the patient, inpatient versus outpatient. It may change based on whether that patient is new or established patients to you, or whether it's a consultation service. The fifth digit of code is what we call the level of code. And the level is chosen based on your documentation of three key components, history, exam, and medical decision-making. Notice, I didn't say SOAP, subjective, objective, assessment, and plan. SOAP notes went out in 1992. Okay, that was a long time ago. And the E AND M notes format, using the buzzwords of E and M, came in, in 1992. 20 years ago, we've been using E and M code. So I don't want to see SOAP notes. It's all E and M, using the history, exam, and medical decision making verbiage. Now typically, you'll choose your code based on your history, exam, and medical decision-making documentation. There will be occasions where you might choose the code based on your time, spent counseling the patient or coordinating the care. And we'll talk about that in a little bit. So the steps involved in choosing an E and M code in these slides are set up to show you what it's like for choosing your office in E and M code, since that's where the majority of your billable E and M services will occur. The first step is to choose the category of code, the fourth digit. So outpatient consultation, 9924. New patient, 9920. Established patient, 9921. And then we choose the level of history. And so you can see that there are four levels, expanded problem focused. And you can see the code associated with each level is listed. Expanded problem focused, detailed, and comprehensive. And underneath each type of level of history are the documentation requirements. So you notice that a chief complaint is required for every billable encounter, and then some sort of history of the present illness is also required. And then we get to the system review, the review of systems, and then the past, family, and social history. Step three, it then is what level of exam did I document? Was it problem focused, expanded problem focused, detailed, or comprehensive? You can see the same terms. And CPT describes the each level. And you can see that as the higher the level, the higher the fifth digit, the more extensive the documentation. Now, Medicare has some specific guidelines on choosing the level of exam that further clarifies or puts into more detail what CPT says. 'Cause these descriptions right here are CPT terminology. And it's pretty vague. You know, really what is a limited exam versus an extended exam, versus a complete exam. CPT does not specify, but Medicare does. In the 1995 guidelines for Medicare describes a comprehensive exam, which is required for a level four or five consultation or new patient code, but a comprehensive exam is encompassing eight organ systems. Okay. And that can oftentimes be onerous for a neurosurgeon where we kind of stick to examining the spine. And so it's gonna be hard to get eight organ systems. You'd have to listen to the abdomen or listen to the lungs or the heart. So that's the level of exam. Then we have medical decision-making, which also has four types: straightforward, low complexity, moderate complexity, and high complexity. And to choose that level of medical decision-making, we have to think about three things: data reviewed, diagnosis and management options, and risks to the patient. And of these three elements, we would only have to consider two of the three. 'Cause there will be occasions when you see a patient and there's no data that you reviewed, or you didn't, you're not ordering any testing, but the patient will always have a diagnosis. And there will always be some inherent risk to that patient based on their diagnosis or the treatment plan. And then you put it all together to choose the right code. So for outpatient consultation or new patient codes, we have to meet or exceed all three of the three key criteria, the history, exam, and medical decision-making. So if you had documented a comprehensive history and a detailed exam, and your medical decision making was moderate complexity, we would default to the lowest of the three criteria. So that would be a level three outpatient or new patient code. On the established patient visit, the 9921 codes, we have to meet or exceed only two of the three key criteria, because there are gonna be times when you see patients, like if you're doing a followup after x-rays or imaging, where you might not examine the patient, but you're going to retake the history and come up with a diagnosis and a plan. So only two of the three count. Now, the 99211 code does not require the presence of a physician. So by default, physicians, you would bill the 99212 at a minimum when you see a patient. Now in the office, in our consultation codes, the 9924 codes. As I mentioned, there are four level or five levels, the 99241 to 99245. And the documentation criteria is listed for each level. And then the time associated with each code, and this comes straight from the CPT book. And the time spent is, can be the overarching factor. So it can trump history, exam, and medical decision-making when the purpose of the visit, or it becomes counseling the patient. So you would document your total amount of time with the patient in addition to your history, exam, and medical decision-making. Then you would also say, I spent 40 minutes with Mrs. Smith, the majority of are greater than 50% was spent counseling her on her diagnosis of X and the treatment options. And then you can choose that code based on the time, even if you did not meet the other documentation requirements. Now in 2010, Medicare eliminated payment for consultation codes. So you'll notice here, we've got a column for what CPT says as a consultation, 9924 in your office, and what Medicare says, 9920. They say, we don't pay the consultation codes. We're only gonna pay for a new patient or an established patient code. The other criteria for document, for billing a consultation code to non-Medicare payers is you have to document the request for consultation. And we use the term request, not referral. Because a referral implies a transfer of care. And that means that it would not be a consultation code. So we document the request for consultation. And then we also document a separate written report to the requesting physician. And that report needs to be personalized about the patient. You can also send your chart note, but that separate report to the requesting physician must say something about the patient's specific issues. Then the new patient codes, the 9920 codes. You can see the documentation requirements are exactly the same as they are for the consultation codes. And then the time associated with the new patient codes. And a new patient is one who has not received services from a physician of another, of the same specialty neurosurgery in your same group practice in the last three years. An established patient is a patient who has seen you or one of your same specialty neurosurgery partners in the last three years. And again, CPT and Medicare on the same page about this, the use of the codes. In the emergency department, the 9928 codes have little bit different documentation requirements for history, exam, and medical decision-making than the new patient or your office service codes do. And there is no time associated with these codes. And because we see a lot of patients in consultation in the emergency room, again, if you see the patient in the emergency room and you do not see the patient on the floor as an inpatient on the same date of service, CPT says you would bill the outpatient consultation code. Medicare says that's an emergency department code because Medicare doesn't want to pay on the consultation codes. And it is acceptable for both, you and the emergency department physician to both bill the ED code. Now, a consultation, if you see the patient in the emergency room and on the floor on the same data service, then we will default to the inpatient consultation code that day, if it's still a consult, or we would default to the admission code or initial hospital care code, if you become the admitting physician. And Medicare says, regardless, if that patient gets admitted, even if you don't, if you follow that patient to the floor, then you would use the initial hospital care code. And if you admitted, you also have to add the modifier, AI. The admission, the hospital, inpatient consultation codes, the 9925 codes have the same documentation requirements as the outpatient consultation codes. The times are a little bit different. And the requirements for using the consultation codes. Again, you have to document the request for consultation. We can report one consultation code per admission, hospital admission. So if you consulted today, signed off on the case, and they asked you to come back and see the patient in a couple of days during that same admission, then you would not bill a second consult code. You would just bill a subsequent hospital care code. But you do not have to send the doctor, requesting physician a separate report. Your consultation report in that chart suffices. Now remember Medicare says, we don't want to pay for consultation codes. So Medicare says, the first time you see a patient in consultation and inpatient, then you use the initial hospital care codes. And if you don't meet the documentation requirements for the initial hospital care codes, then you can use the subsequent hospital care codes. And this slide shows the documentation requirements for the initial hospital care codes and the time requirements. The next slide is for subsequent hospital care, so these are for your follow-up visits when you're not in a global period. Three choices, 99231, 32, and 33, and then the time associated. Now in the inpatient setting, the time associated with the code, can be your total time spent on that floor, coordinating care, talking to the family, in addition to your bedside time. So you would just document that time in your chart note to justify the code that you bill. And then if you were the admitting physician of record or you are now the discharging physician of record. So maybe the patient's been transferred to your service and you are not in a global period, then you can build for the discharge on 99238, when that discharge activity took you 30 minutes or less. 99239, when that discharge activity was more than 30 minutes. And again, I mentioned counseling and coordination of care coding based on time. In the outpatient setting, when counseling or coordination of care dominates the patient, physician, patient and family encounter in the office, then you can choose the code based on time. So it's face-to-face time with the patient and, or family in the office. In the hospital setting, it's unit or floor time, coordinating care, talking to the nurses, talking to the family, and at the bedside. Three modifiers for E and M codes to be aware of. Modifier 24, which is appended to the E and M code. When you see a patient for different reason in a post-op period. So let's say you saw, you did an ACDF on a patient, and they come back for their post-op appointment. And now they're complaining of a new problem of carpal tunnel. So you should bill an established patient visit for that, modifier 24 for unwritten. Your diagnosis code will change the carpal tunnel. Modifier 25 said, it says, I did a significant separately identifiable E and M service on the same day as a procedure, a minor procedure, like an injection on the same day. So if you did a translaminar epidural injection is 63211 on the same day as a console, then you would build both codes, and modifier 25 on the consult code. And modifier 57 is the decision for surgery, when the procedure you're going to do, it has a 90 day global period. It's considered a major procedure and you see that patient, you make that decision for surgery the day before, or the day of. And again, this is not for your routine pre-op visit or H and P, this is when your decision for surgery was made. So typically, this is for your urgent care. You see the patient in the emergency room. You take the patient to the OR that day. Modifier 57 goes on the E and M code, and then you bill for the procedure code as well. Now, some of the resources that I would recommend in your quest for coding excellence, would be the AANS website, as well as for information on where the AANS coding courses are. Each year, we have four to five courses, standalone courses. And then there's always two courses at the AANS, annual meeting as well as at the CNS meeting. We are highly recommend the neurosurgery executives, resource value, and education society, or nerves for your office manager or practice administrator, or for you, physician. If you are heavily involved in the business side of your practice, there are several physician members of nerves. On the KZA website, we have some great practice management tips, coding tips that are all free of charge. And then the Medicare website is also available. The nice thing about Medicare is that, they publish their rules. I'd like to thank on Dr. Chang for moderating the sessions for me. And to you, Dr. Cohen for asking me to do this.

- Well, Karen, I want to thank you very much for your time really, excellent talk. Something very important for all of us. Joe, as always, thank you again for your time. We do really appreciate it. And we'll look forward to working with you guys again.

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