Although the majority of a neurosurgeon’s practice occurs in the office or operating room, the nature of neurosurgical problems also may require evaluating and managing patients in the emergency room. This Coding Corner will examine the options for describing these emergency services.
Until a patient is admitted to the hospital, the patient is considered an outpatient, according to Current Procedural Terminology, CPT. Services performed in the office or other ambulatory care facilities are coded using CPT’s Office or Other Outpatient Service codes. If an ER physician asks a neurosurgeon to consult on an ER patient’s case, the neurosurgeon has several options for proper coding of this service. If the patient is discharged from the ER by the ER physician, then the neurosurgeon may use Office and Other Outpatient Consultations codes 99241-99245. If the neurosurgeon admits the patient to the hospital, then the Initial Hospital Care codes 99221-99223 should be used. However, if another attending physician admits the patient, then the Initial Inpatient Consultation codes 99251-99255 should be used.
It is important to understand that coders may run into difficulties with these claims based on where the particular evaluation and management service was performed. Some insurers expect ER services of any sort to be coded with the ER Service codes 99281-99285. While it is correct that these codes can be used by any physician, it is expected that ER physicians will bill for their services with these codes. If a neurosurgeon asks a patient to go to the ER for evaluation by the neurosurgeon (outside of the normal scope of services associated with a procedure previously done) and the patient is not admitted, then these codes are most appropriate for the neurosurgeon to use. However, if the ER physician also has seen the patient and will use the same codes, the insurer might not pay another identical code that is submitted by the neurosurgeon. It is possible to use Office and Other Outpatient Service codes for ER services when the patient is not admitted to the hospital, since the ER is an ambulatory care facility.
As with any evaluation and management service provided within 24 hours before performing a procedure, for payment of both the service and the procedure, a modifier must be appended to the code. There are two modifiers that are used to designate an evaluation and management code as the encounter during which the decision for surgery or other procedure was made. If a procedure such as a nerve injection is performed at the bedside, then the -25 modifier would be appended to the code, while if a procedure is performed in the operating room, then the -57 modifier would be used.
There may be circumstances, such as acute trauma, for which the neurosurgeon provides critical care services. Although Critical Care Service codes are commonly associated with intensive care unit patients, these codes are chosen based upon the type of service provided rather than where the service is provided. In order to use a critical care code, the patient must be critically ill or injured such that the malady impairs one or more vital organ systems with a high probability of imminent or life-threatening deterioration in the patient’s condition. These services require decision-making of high complexity in assessing, manipulating and supporting single or multiple organ systems.
The codes 99291-99292 reflect the total time spent by the physician providing critical care services, even if the time is not continuous. However, the time recorded should be that exclusively devoted to treating the patient, including review of test results or imaging, consultation with other medical staff, discussing management with the patient’s family, or documenting these services in the medical record. CPT allows for critical care and other evaluation and management services to be reported by the same physician treating the same patient in a single day to account for those services that do not meet the criteria of critical care services. The code 99291 is used for critical care service between 30 minutes and 74 minutes, and subsequent time is billed using 99292 for every additional 30 minutes.
It is important for the neurosurgeon to be familiar with the nuances of coding for emergency services. Although a series of ER Service codes are available, there are several circumstances in which the other codes described in this article more accurately reflect the service that has been provided. Proper coding of these services should lead to appropriate compensation for the actual service provided.
Gregory J. Przybylski, MD, is professor and director of neurosurgery at JFK Medical Center in Edison, N.J. He is a member of the AANS/CNS Coding and Reimbursement Committee and on the faculty for AANS coding and reimbursement courses. He also is council director of socioeconomic affairs for the North American Spine Society and program chair of its coding update courses.