Parkinson's Toolkit

Here are some guidelines that you can use when addressing this issue:

Codes for PD and Parkinsonism

ICD-9 code: 332     Parkinson’s disease

ICD-9 code: 332.1  Secondary parkinsonism

ICD-9 code: 333     Other extrapyramidal disease and abnormal movement disorders

Billing codes

99201-99205        New patient (not seen by specialists in your practice within 3 years) 

99211-99215        Established patient  

99354-99359        Prolonged Services (bill level of service then prolonged service for additional time

                          greater than 30 minutes)                                 

   Modifiers            Modifier 25–Same day separate procedure (EM visit and procedure with separate 

                            documentation such as DBSⁱ or botulinum injection) 

               

Coding

There are two set of guidelines for billing, the 1995 or the 1997 guidelines. You must check with your institution, what set is being used. The following information is based on the 1997 E/M guidelines.

The following components will determine the codes that you can use when billing:

History

History levels are determined by chief complaint (CC), history of present illness (HPI), review of systems (ROS) and past, family, and/or social history (PFSH).

• CC: must always be present
• HPI: quality, modifying factors, duration, location, intensity, etc
• Personal history, family history, social history
• You should document whether you conducted a review of (a) problem pertinent system (1 system), (b) an extended review (2-9 systems) or a (c) complete review (10 or more systems); those systems with positive or pertinent negative responses must be individually documented

HPI	ROS	PFSH	Type of history
Brief (1-3)	N/A	N/A	Problem-focused
Brief	Problem-pertinent (1 system, ie, neuro)	N/A	Expanded problem focused
Extended (≥4)	Extended (2-9 systems)	Pertinent	Detailed
Extended	Complete (more than 10 systems)	Complete (2 of 3 for established pt; all 3 for new pt)	Comprehensive

For purposes of ROS, the following systems are recognized:

• Constitutional symptoms (eg, fever, weight loss) • Eyes

• Ears, Nose, Mouth, Throat • Cardiovascular • Respiratory • Gastrointestinal

• Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurological

• Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic

Notes:

• Remember that in PD you can find motor and non-motor symptoms. Review the list of symptoms in PD found in this for a better guide on what systems you should review. You will find that almost every system could or should be reviewed in PD.
• History can be obtained by a third party if patient is unable to provide.
• ROS: Be sure to state negative items as well as positive.

Examination

1997 E/M guidelines require you to document the examination using specific bullets. Document if you are conducting a problem focused examination (1-5 bullets); an expanded problem-focused (6+ bullets); a detailed examination (at least 2 bullets from 6 organ systems OR 12 bullets from 2 or more organ systems); or a comprehensive evaluation (2 bulletsfrom each of nine organ systems). For details on the bullets click here.

These types of examinations have been defined for general multi-system and the following single organ systems:

• Cardiovascular • Ears, Nose, Mouth and Throat • Eyes • Genitourinary (Female)

• Genitourinary (Male) • Hematologic/Lymphatic/Immunologic • Musculoskeletal

• Neurological • Psychiatric • Respiratory • Skin

Medical Decision Making

Medical decision making is divided into four levels: (a) Straight-forward, (b) Low complexity, (c) Moderate complexity, and (d) High complexity. Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by (a) the number of diagnoses or treatment options, (b) the amount or complexity of data to be reviewed and, (c) the risk of complications and/or morbidity/mortality. The following chart shows the progression of the elements for each level of medical decision making. Two of the three elements in the table must be either met or exceeded:

To determine the billing code put it all together:

		99211	99212	99213	99214	99215
HX	HPI ROS PFSH	Phys Sup	1 No No	1 1 No	4 2 1	4 10 2 (3 new)
Exam						All bulleted
Decision 2 of 3			Straight forward	Low complexity	Moderate complexity	High complexity
	Dx		Self limited	Est PD	Est PD, new/mult prob/mod decline	Acute, abrupt, sig decline, >4dx
	Data
	Mgmt options			Rehab, OTC	Rx mgmt	Drug tox, EOL