Coding & Billing for the Electrodiagnostic Practice

An AANEM TeleconferenceDecember 16, 2009December 16, 2009

The AnnouncementThe Announcement• 2010 will bring some important coding changes for2010 will bring some important coding changes for

reporting nerve conduction studies • Providers who utilize preconfigured electrode arrays

need to make sure they are ready for these changes • A more complete definition for traditional nerve

d ti t di ill l b i l t d i 2010conduction studies will also be implemented in 2010; this clarification will affect some providers more than othersothers

• Finally, make sure you are correctly coding other EDX studies, from H reflexes to F waves

2

2010 Changes in Coding and P liPolicy

• NCS codingNCS coding– New section header

New nerve conduction code– New nerve conduction code• Consult coding

C S– CMS eliminates consult codes

3

4

5

6

Rationale for Code 95905Rationale for Code 95905

• Code 95905 has been established to reportCode 95905 has been established to report the performance of motor and sensory nerve conduction using pre-configured arraysg p g y

• New introductory language to assist in differentiating nerve conduction studiesdifferentiating nerve conduction studies performed with individually placed stimulating electrodes from tests performed with ppreconfigured electrodes has also been added

7

New Code 95905New Code 95905

• Code 95905 describes nerve conductionCode 95905 describes nerve conduction tests when performed with preconfigured electrodes customized to a specific anatomic psite

• 95905: Motor and/or sensory nerve95905: Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, y( ), p y y y,each limb, includes F-wave study when performed, with interpretation and report

8

Parentheticals With Code 95905Parentheticals With Code 95905

• Report 95905 only once per limb studiedReport 95905 only once per limb studied• Do not report 95905 in conjunction with

95900 95904 95934 9593695900-95904, 95934-95936

9

Modifier 51 ExemptionModifier 51 Exemption

• Similar to codes 95900 95903 and 95904Similar to codes 95900, 95903 and 95904, a modifier 51 exemption designation has been added to code 95905 as thisbeen added to code 95905, as this procedure is usually performed with other services and thus the pre- and post-services, and thus the pre and postservice activities in this service are minimal and already reflect a reducedminimal and already reflect a reduced relative value unit (RVU)

10

Clinical Example (95905)Clinical Example (95905)• A 42-year-old female data entry clerk reported that, although she

had had no injuries and during the day she felt okay, she woke in the middle of each night for the past 2 weeks with a numb, aching, burning feeling in her right hand that was relieved by holding her h d d d h ki it bbi it d i ld t ithand down and shaking it, rubbing it and running cold water over it

• Physical examination reveals weakness of right thumb abduction; wasting of the right thenar eminence; numbness of the palmar

t f th i ht th b i d fi d iddl fi daspects of the right thumb, index finger and middle finger; and a Tinel’s sign over the right median nerve at the carpal tunnel

• History and exam are reported separately with evaluation and t [E/M] dmanagement [E/M] codes

• Nerve conduction testing using preconfigured arrays for the right arm is performed

11

Description of Procedure (95905)Description of Procedure (95905)

• The physician reviews a summary ofThe physician reviews a summary of electrodiagnostic data from each nerve tested and assesses it in the context oftested and assesses it in the context of comparison to normal values and the patient’s history and physical examinationpatient s history and physical examination

12

RVUs for Codes 95900-95905RVUs for Codes 95900 95905Professional Component Technical Component

95900 0.59 0.91 95903 0.83 0.9395904 0 48 0 8595904 0.48 0.85 95905 0.08 2.03

According to the 2010 Medicare Physician Fee Schedule, the new code has 0.05 physician work relative value units (RVUs). The higher technical component for the new code reflects the higher cost of the disposable supplies for the automated test.

13

14

Traditional EMG and Nerve Conduction StudiesNew Header, Old Codes…

New Section Header - 1New Section Header 1• The following applies to nerve conduction testsThe following applies to nerve conduction tests

(95900-95904): Codes 95900-95904 describe nerve conduction tests when performed with individually

l d ti l ti di d d l t dplaced stimulating, recording, and ground electrodes• The stimulating, recording, and ground electrode

placement and the test design must beplacement and the test design must be individualized to the patient’s unique anatomy

• Nerves tested must be limited to the specific nervesNerves tested must be limited to the specific nerves and conduction studies needed for the particular clinical question being investigated

16

New Section Header - 2New Section Header 2• The stimulating electrode must be placed directlyThe stimulating electrode must be placed directly

over the nerve to be tested, and stimulation parameters properly adjusted to avoid stimulating

th b hother nerves or nerve branches• In most motor nerve conduction studies, and in

some sensory nerve conduction studies bothsome sensory nerve conduction studies, both proximal and distal stimulation will be used

• Motor nerve conduction study recordings must beMotor nerve conduction study recordings must be made from electrodes placed directly over the motor point of the specific muscle to be tested

17

New Section Header - 3New Section Header 3• Sensory nerve conduction study recordings must beSensory nerve conduction study recordings must be

made from electrodes placed directly over the specific nerve to be tested

• Waveforms must be reviewed on site in real time, and the technique (stimulus site, recording site, ground site filter settings) must be adjusted asground site, filter settings) must be adjusted, as appropriate, as the test proceeds in order to minimize artifact, and to minimize the chances of unintended stimulation of adjacent nerves and the unintended recording from adjacent muscles or nervesnerves

18

New Section Header - 4New Section Header 4• Reports must be prepared on site by the examiner, and p p p y ,

consist of the work product of the interpretation of numerous test results, using well-established techniques to assess the amplitude latency and configuration ofto assess the amplitude, latency, and configuration of waveforms elicited by stimulation at each site of each nerve tested

• This includes the calculation of nerve conduction velocities, sometimes including specialized F-wave indices along with comparison to normal valuesindices, along with comparison to normal values, summarization of clinical and electrodiagnostic data, and physician or other qualified health care professional i t t tiinterpretation

19

New Header Clarifies CodingNew Header Clarifies Coding

1 Testing should be limited to those nerves1. Testing should be limited to those nerves necessary to address the clinical question being investigatedbeing investigated

2. Standardized screening tests are not the same as carefully designed NCSs and dosame as carefully designed NCSs and do not entail the same physician work

3 W f t b i d it3. Waveforms must be reviewed on site4. Reports must be prepared on site

20

Nerve Conduction StudiesNerve Conduction Studies

21

Nerve Conduction Studies and F W T iF-Wave Testing

• 95900: Nerve conduction, amplitude and95900: Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study

• 95903: … motor, with F-wave study• 95904: … sensoryy• (For listing of nerves considered for separate

study, see Appendix J)• (Report 95900, 95903, and/or 95904 only once

when multiple sites on the same nerve are stimulated or recorded)

22

H-Reflex TestingH Reflex Testing

• 95934: H-reflex amplitude and latency95934: H reflex, amplitude and latency study; record gastrocnemius/soleus musclemuscle

• 95936: … record muscle other than gastrocnemius/soleus musclegastrocnemius/soleus muscle

• (To report a bilateral study, use modifier 50)50)

23

Using 95900 and 95903 TogetherUsing 95900 and 95903 Together

• Some payers reject code 95900 and/orSome payers reject code 95900 and/or code 95903 whenever they are reported together indicating 95900 is a componenttogether, indicating 95900 is a component code of 95903

• This is true only if 95900 and 95903 are• This is true only if 95900 and 95903 are reported for the same motor nerve conduction study but not true if reportedconduction study, but not true if reported for studies of different motor nerves

24

What is the Mixed Nerve Code?What is the Mixed Nerve Code?

• Mixed nerves contain motor and sensoryMixed nerves contain motor and sensory nerve fibers

Stimulate and record from a mixed nerve– Stimulate and record from a mixed nerve• How to code for these studies?

U 95904 th d ti– Use 95904, the sensory nerve conduction code

25

How to Count Units of NCSHow to Count Units of NCSA. Lateral antebrachial cutaneous sensory nerveB. Medial antebrachial cutaneous sensory nerveC. Medial brachial cutaneous sensory nerveD. Median nerve

1. Median sensory nerve to the first digit2. Median sensory nerve to the second digit3. Median sensory nerve to the third digity g4. Median sensory nerve to the fourth digit5. Median palmar cutaneous sensory nerve6. Median palmar mixed nervep

E. Posterior antebrachial cutaneous sensory nerve…

26

Multiple Sites RuleMultiple Sites Rule

• One nerve, manyOne nerve, many segments = one unit

• Many nerves, one or y ,more segments each = many units

27

Number of Studies/DiagnosisNumber of Studies/DiagnosisNCS Other EMG Studies

Motor NCS

Indication Needle EMG

Motor NCS With

and/or WithoutF Wave

Sensory NCS H-Reflex

Neuromuscular Junction Testing

(Repetitive Stimulation)F Wave

Weakness, fatigue, cramps, or twitching (focal)

2 3 4 2Weakness, fatigue, cramps, or twitching (general)

4 4 4 2Pain numbness or 1 3 4 2Pain, numbness, or tingling (unilateral) 1 3 4 2Pain, numbness, or tingling (bilateral) 2 4 6 2“The appropriate number of studies to be performed is based upon the physician’s discretion.”

28

ElectromyographyElectromyography

29

The Basic Limb EMG CodesThe Basic Limb EMG Codes

• 95860: Needle electromyography; one95860: Needle electromyography; one extremity with or without related paraspinal areas

• 95861: … two extremities with or without related paraspinal areasrelated paraspinal areas

• 95863: … three extremities with or without related paraspinal areasrelated paraspinal areas

• 95864: … four extremities with or without related paraspinal areasrelated paraspinal areas

30

Some “Limited” EMG StudiesSome Limited EMG Studies

• Needle electromyography;Needle electromyography;• 95869: … thoracic paraspinal muscles

(excluding T1 or T12)(excluding T1 or T12)• 95870: … limited study of muscles in one

extremity or non-limb (axial) musclesextremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal cranial nerve supplied musclesparaspinal, cranial nerve supplied muscles, or sphincters

31

Proper Use of Needle EMGCPT C d 9 860 9 864CPT Codes 95860-95864

• Extremity muscles innervated by threeExtremity muscles innervated by three nerves or four spinal levels must be evaluated with a minimum of five musclesevaluated, with a minimum of five muscles studied per limb

• One cannot bill paraspinals separately• One cannot bill paraspinals separately with these codes

Th i i l 95869– Thoracic paraspinals - use 95869– Cervical and lumbar paraspinals - use 95870

32

Proper Use of Needle EMGCPT C d 9 869CPT Code 95869

• CPT code 95869 should be used whenCPT code 95869 should be used when exclusively studying thoracic paraspinal muscles excluding T1 or T12muscles, excluding T1 or T12

• One unit can be billed, regardless of the number of levels studied or whethernumber of levels studied or whether unilateral or bilateral

C t b bill d ith d 95860 95864 if– Cannot be billed with codes 95860-95864 if only T1 and/or T2 paraspinals are studied with an upper extremityan upper extremity

33

Proper Use of Needle EMGCPT C d 9 8 0CPT Code 95870

• CPT code 95870 can be billed at one unitCPT code 95870 can be billed at one unit per extremity or for muscles on the thorax or abdomen (unilateral or bilateral)or abdomen (unilateral or bilateral)

• One unit per cervical or lumbar paraspinals (unilateral or bilateral)paraspinals (unilateral or bilateral), regardless of the number of levels tested

Sh ld t b bill d h i l– Should not be billed when paraspinals corresponding to an extremity are tested and codes 95860-95864 are also billedcodes 95860-95864 are also billed

34

About CPT Modifiers

35

Can I code for an E/M service and a procedure provided forand a procedure provided for the same patient on the same

date?

36

37

Modifier 25Modifier 25• Significant, Separately Identifiable Evaluation g , p y

and Management Service by the Same Physician on the Same Day of the Procedure or Other Serviceor Other Service

• Add modifier 25 to the E/M code• Different diagnoses are not requiredDifferent diagnoses are not required

– Classic example: performance of a lumbar puncture and E/M service on the same dateSome carriers: use with any E/M services– Some carriers: use with any E/M services performed on the same date as neurodiagnostic procedures

38

How do I code for a procedure I do in the hospital?

39

Modifier 26Modifier 26• Professional Componentp• Certain procedures are a combination of a

physician component and a technical componentcomponent

• When the physician component is reported separately, the service may be identified byseparately, the service may be identified by adding modifier 26 to the usual procedure code

U d ith di ti t t f d– Used with neurodiagnostic tests performed on inpatients anywhere or on outpatients in the hospital

40

If I do a bilateral procedure, do I always bill for two units?

41

Modifier 50Modifier 50

• Bilateral ProcedureBilateral Procedure• Used when a unilateral procedure is done

on both sideson both sides• H-reflex codes are defined as unilateral

studiesstudies– Add modifier 50 to the H-reflex codes 95934,

95936 for bilateral studies– Never use two units of the H-reflex codes for

bilateral studies!

42

I couldn’t complete theI couldn t complete the procedure.

What can I do now?

43

Modifier 52Modifier 52

• Reduced ServicesReduced Services• Under certain circumstances a service or

procedure is partially reduced orprocedure is partially reduced or eliminated at the physician’s discretionU difi 52 f• Use modifier 52 for:– Unilateral SEPs– Long-term EEG monitoring between 6 and 12

hours

44

Modifier 53Modifier 53

• Discontinued ProcedureDiscontinued Procedure• Due to extenuating circumstances or those

that threaten the well being of the patientthat threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure wassurgical or diagnostic procedure was started but discontinued

A f l l b t ld b– An unsuccessful lumbar puncture could be coded using this modifier

45

They rejected some motor nerveThey rejected some motor nerve conduction studies.

Help!

46

Modifier 59Modifier 59

• Distinct Procedural ServiceDistinct Procedural Service• Modifier 59 is used to identify

procedures/services that are not normallyprocedures/services that are not normally reported together, but are appropriate under the circumstancesunder the circumstances– Flag studies mixing motor nerve conductions

without and with F waves (95900 and 95903)without and with F-waves (95900 and 95903) using this modifier

• Add modifier 59 to the lesser code (95900)Add modifier 59 to the lesser code (95900)

47

CMS Eliminates Payment for Consultations in 2010

Thanks to Mary McDermott and Marc NuwerMary McDermott and Marc Nuwer

(AAN Webinar 12/08/09)

48

No More Consult Codes For M diMedicare

• Medicare disallows use of the Consult codes 99241-99255 in 2010

• Medicare will not pay as a secondary carrier for these codes even when the primaryfor these codes even when the primary requires use of these codes

• Exception: use consult “G”codes forException: use consult G codes for Medicare teleconsultation

• No announcement yet about Medicaid or T iTricare

• Most commercial carriers continue to use Consult codesConsult codes

49

In Place of Outpatient Medicare C l C dConsult Codes

• Use New Outpatient Visit Codes 99201-Use New Outpatient Visit Codes 9920199205 for a consultation on a patient not seen previously by you or anyone in your

i hi h l 3 l dgroup within the last 3 calendar years• Use Established Patient Visit Codes 99211-

99215 if th ti t h b f t99215 if the patient has been seen face-to-face by you or a member of your group within the last 3 calendar yearsthe last 3 calendar years– Even if being seen for a new problem– Reading an EEG is not face-to-faceg

50

New vs Established Patient?New vs. Established Patient?

• When is an outpatient “new”?When is an outpatient new ?– When not seen face to face within 3 years by

you or any neurologist in your group withyou or any neurologist in your group with same tax ID or Group NPI

– Subspecialties of neurology not recognizedSubspecialties of neurology not recognized• What if the patient now is seen in office

within 3 years for new problem?within 3 years for new problem?– It is still is an established patient

51

In Place of Medicare Inpatient C lConsults

• Use Initial Hospital Care codes 99221-Use Initial Hospital Care codes 9922199223 for the initial consultation provided to a hospital inpatientto a hospital inpatient

• For follow-up days for inpatient consults, continue to use the Subsequent Daycontinue to use the Subsequent Day Hospital Care codes 99231-99233

52

Inpatient Consult FAQsInpatient Consult FAQs

• I thought only the admitting physician ofI thought only the admitting physician of record could bill for the Initial Hospital Care (Admission) codes 99221-99223? ( )– CMS has developed a new modifier - AI for

use by the admitting physician of record• What if the admitting physician forgets to

use the AI modifier? – “The payment for both the admission and the

consult may delayed if the required modifier is not used”not used

53

Considerations to Mull OverConsiderations to Mull Over…• Pesky consult requirements go away for CMS patients• You will still want to document the requests (e.g. for

concurrent care)• What if Medicare is secondary?What if Medicare is secondary?

– Primary may pay more - take the money and write off• Re-tool your front end - mistakes will be costly• Develop a strategy for inpatients• Develop a strategy for inpatients

– Obtain and verify demographic information– New modifier for CMS Admits: - AI

M it th t t d• Monitor other contracted payers– Currently this only affects CMS patents

54

The 2010 Reimbursement PictureThe 2010 Reimbursement Picture1. Elimination of consult codes with recommended cross walks2. Increase in reimbursement for follow-up codes

– If you consider a patient encounter (especially in the hospital) as the total of all visits, this increase may mitigate the decrease in reimbursement for the initial visitdecrease in reimbursement for the initial visit

3. Increase in practice expense reimbursement for certain procedures– Will help procedures in the office, but not the hospitalp p , p

4. Possible inclusion in the 10% E/M bonus pool, which could also mitigate loss of consult codes

• Each practice has a different mix of services and procedures, h i f h l ill diff id blso the impact of the new rules will differ considerably

• Financial impact calculator on AAN.com:<http://www.aan.com/news/?event=read&article_id=8527>

55

Keep Up To Date With AANEM.org

56

57

58

AANEM org Practice Issues AreaAANEM.org Practice Issues Area

• Legislationg• Coding• Recommended Policy• List of Nerves• Practice Guidelines• Position Statements• Standard Response Letters

T h l Lit t R i• Technology Literature Reviews• AANEM News

59

60

61

62