eglobaltech CBR Electrodiagnostic Testing Moderator: Molly Wesley July 09, :00 p.m. ET

Transcription

1 CBR Electrodiagnostic Testing July 09, :00 p.m. ET

2 Contents Miscellaneous Topics... 2 NCS Codes (95905, )... 4 EMG Codes (95860, 95861, )... 4 NCS & EMG Combination Codes ( )... 5 Medically Necessary and Reasonable... 5 General... 5 Report Methodology & Results... 6 July 09, 2014, 3:00 p.m. ET

3 Questions & Answers The information provided in this Question & Answer session does not supersede or alter the coverage and documentation policies as outlined in the local coverage determinations (LCD) and Policy articles for the A/B Medicare Administrative Contractors (MAC). Please refer any specific questions you may have to the A/B MAC for your region. Miscellaneous Topics WHAT IF THE PATIENT REFUSES NEEDLE examination? As stated in the webinar, the patient has the right to refuse any treatment or diagnostic test that is offered. With that being said, normally both needle electromyography (EMG) and nerve conduction studies (NCS) are required in order to diagnose a disorder of the peripheral nervous system. All electrodiagnostic Local Coverage Determinations (LCDs) specify that a neurological evaluation includes NCS performed in conjunction with EMG with the exception of NCS for carpal tunnel. NCS performed alone, except for carpal tunnel, are considered a screening service and as such are not covered by Medicare. IF A NEUROLOGIC EXAMINATION IS performed and recorded with nerve conduction studies, is this sufficient for coverage? Keep in mind we don t bill for neurologic examination as part of nerve conduction studies. All active and future LCDs for Nerve Conduction Studies and Electromyography include a statement which says that the electrodiagnostic evaluation is an extension of the neurological portion of the physical examination. These policies go on to say that both EMG and NCSs are usually required for a clinical diagnosis of peripheral nervous system disorders and the performance of one type of testing does not eliminate the need for the other. Any specific clinical situations should be discussed the Carrier Medical Director for your state. IF A PATIENT IS UNABLE TO TOLERATE needle EMG, should this be billed with modifier 53 indicating an attempted test? May they be rescheduled at a later date for the needle EMG portion of testing? It may be appropriate to append the 53 modifier if the diagnostic procedure July 09, 2014, 3:00 p.m. ET Page 2 of 8

4 was started but was unable to be completed. The appropriateness of rescheduling the test may depend on whether or not the physician feels that the patient would be able to tolerate the procedure at another time. WHEN PERFORMING EMG/NCV ON BUE testing 5 nerves on each extremity, do I bill x 2 and a x 2 or a x 1 and a x 2? The correct codes would depend on how many nerve conduction studies were done. If only one type of nerve conduction study was done on each nerve then the correct codes would be x 2 units and x 1 unit. IS IT APPROPRIATE TO BILL AN OFFICE visit code along with any of these tests? An evaluation and management (E/M) service is normally included in the examination performed immediately prior to and during NCS and/or EMG. If the (E/M) service is a separately identifiable service, the record must document the medical need and the evaluation and management code should be billed with the 25 modifier appended. WHEN YOU SAY NUMBER OF STUDIES, do you mean the number of nerves tested? No, we mean the number of studies performed. A study is defined as a sensory conduction test, a motor conduction test with or without F-wave or an H-reflex test. Each type of test for each nerve would be added to get a total number of tests keeping in mind that each study is counted only once for each nerve, even if multiple sites on the same nerve are stimulated or recorded. IN CASE OF HEMIDIAPHRAGM, IF YOU do bilateral studies is it still only one code that can be used rather two times the code? The definition of hemidiaphragm is half of the diaphragm. In this case, if both the right and left hemidiaphragms were studied it would be correct to bill the procedure code with either 2 units or with one unit along with the 50 modifier. I HAVE BEEN DENIED PAYMENT CITING duplication of services for billing a and a with NCV codes and This was coded when performing bilateral extremities studies one with 5 nerves the other with 4 nerves. Why was payment denied? We are unable to give specific reasons for claim denials. We would encourage you to contact the specific MAC who processed your claim for information regarding billing and coding. July 09, 2014, 3:00 p.m. ET Page 3 of 8

5 DO WE NEED TO DO ELECTROMYOGRAPHY to diagnose painful radiculopathy with no motor deficit? Specific clinical questions should be discussed with the Carrier Medical Director in your state so that you can share information specific to the case. NCS Codes (95905, ) WE HAVE MOSTLY SENIORS WITH neuropathy and radiculopathy, so I often end up doing 9-11 studies=95911 and 12. It is hard to differentiate 1 from other, and others have both diagnoses, so it is hard to cut the number of studies without compromising the quality. What is your recommendation? To ensure that you receive the coverage information specific for your jurisdiction, please direct your question to the Carrier Medical Director for your state. PLEASE EXPLAIN CPT would be used when the total number of studies completed met or exceeded 13. A study is defined as a sensory conduction test, a motor conduction test with or without F-wave or an H-reflex test. Each type of test for each nerve would be added to get a total number of tests keeping in mind that each study is counted only once for each nerve, even if multiple sites on the same nerve are stimulated or recorded. IS TO BE REPORTED PER NERVE or per extremity? The answer is neither. CPT codes in the to range are reported per study. CPT would be used when the total number of studies completed equaled 7 or 8. A study is defined as a sensory conduction test, a motor conduction test with or without F-wave or an H-reflex test. Each type of test for each nerve would be added to get a total number of tests keeping in mind that each study is counted only once for each nerve, even if multiple sites on the same nerve are stimulated or recorded. EMG Codes (95860, 95861, ) CAN EMG BE PERFORMED ON A DIFFERENT day from NCS? Yes, CPT codes and are used when EMG studies are done but no nerve conduction studies are performed on the same date of service. July 09, 2014, 3:00 p.m. ET Page 4 of 8

6 WHAT IS MAX NUMBER OF UNITS YOU can bill 95860, 1 or 4? CPT code describes a needle EMG on one extremity, with or without related the paraspinal areas. Since there are 4 extremities this code can be billed a maximum of 4 units. NCS & EMG Combination Codes ( ) DOES INCLUDE PARASPINALS? CPT codes and are both add-on codes to be used in conjunction with codes from the series. The description for is the same as prior to the placement of the semicolon describes a limited study while describes a complete study of 5 or more muscles. The description for both codes states with related paraspinal areas, when performed. WHAT CODE DO YOU USE IF THE DOCTOR does not do paraspinals? The answer above also applies to this question. Any description that comes before the semicolon applies to the indented code below. In the case of and the description states with related paraspinal areas, when performed. So the choice of the correct code is based on the study being limited or complete and not whether or not the paraspinal areas are studied. Medically Necessary and Reasonable IS A REFERRAL FROM A DOCTOR TO evaluate for polyneuropathy in a diabetic patient a CMS covered service? The medical necessity for this service is dictated by the carrier in your state. Please check your local policy as listed in the reference material. General HOW CAN I PRINT THE SLIDES? You can view the entire presentation again (CBR Webinar Recording) or download our handout of the webinar (CBR Webinar Handout) by visiting The recording is available with five business days of the live webinar in the MP4 format and may be paused and July 09, 2014, 3:00 p.m. ET Page 5 of 8

7 restarted at any time. The webinar handout, posted within thirty days of the webinar to the website, includes the text of the webinar with selected images from the slide deck. IS THIS APPROVED FOR AAPC CEUs? This webinar is not approved by the AAPC for CEU credit. Report Methodology & Results DO YOU HAVE A LISTING OF ALL THE providers or tax IDs/group NPIs that received CBRs? A listing of the NPI s that received the CBR is not public information. However, if you think that you should have received a report, please contact the CBR Support Help Desk from 9:00 a.m. to 5:00 p.m. (ET) Monday through Friday. Toll Free Number: cbrsupport@eglobaltech.com. HOW IS IT POSSIBLE TO HAVE AN average number of NCS services per beneficiary greater than 13? Does this mean the provider is necessarily incorrectly submitting >1 unit of service, or could it be because repeat studies are being performed on the beneficiary within the same year? The data used was for one year and included all of the studies done during that time so it would include studies being repeated within that year. I USE AANEM CRITERIA AND STAY within limits, but based on your CBR I am an outlier. Please clarify, why I am an outlier? As stated during the webinar high utilization on the part of a provider may have several different causes including higher patient acuity levels seen in a practice and coding/billing errors. The purpose of this webinar was to educate providers on their utilization in comparison to their peers and does not imply any wrong-doing on your part. FOR NEUROPATHY 4 MOTOR AND 6 sensory per patient, so is correct code. Why does it make me an outlier if I have such complex neuropathy patients with hard to elicit responses in people simply due to their age and neuropathy? Please see the above question. Provider utilization patterns are dependent upon several factors. The purpose of this CBR was to educate providers regarding their utilization July 09, 2014, 3:00 p.m. ET Page 6 of 8

8 patterns so that they can be aware of how they compare to their peers. If the patients referred to a practice have a higher acuity level than one would normally see, they may require additional diagnostic studies in order to correctly determine their diagnosis. FOR SPECIALTY 65 WHY IS AVERAGE payment per beneficiary higher $ vs when average services per beneficiary for NCS (8.69 vs. 8.72), EMG (1.21 vs and NCS & EMG (1.77 vs. 1.78) categories is lower than average per beneficiary? The average allowed charges per beneficiary is the summation of all of the categories, whereas the average services per beneficiary only takes into account those beneficiaries that received services from that category. If your beneficiaries were included in multiple categories, then their allowed charges would be higher than those that only received services from one category. Also the categories have several HCPCS codes included in the grouping. Even though the number of services may be the same, the allowed charges for those services may differ quite drastically within the category. WILL CMS OR ANY OTHER ENTITIES BE receiving the aggregate data and/or the data for each NPI? The CBRs are only made available to the providers who receive them. However, the data is made available to Centers for Medicare & Medicaid Services (CMS) upon request. WHAT WAS THE DATE RANGE THAT the CBR letters were sent/ faxed? The release date for CBR201406: Electrodiagnostic Testing was June 23, 2014, and the reports were disseminated via fax and U.S. postal mail. Due to the large number of reports that were faxed, many suppliers received their CBRs after June 23rd. Also, the U.S. Postal Service delivery times may vary. Faxed reports which were determined to be undeliverable after at least two attempts were re-sent via U.S. postal mail the week of July 7, OUT OF CURIOSITY, WHAT WAS THE trigger for the CBRs in the first place? With the change in coding back in 2013, reimbursement for electrodiagnostic testing had declined extensively. Has there been an increase in utilization of these services since the coding change? Electrodiagnostic testing was chosen as a topic for a CBR because an Office of Inspector General (OIG) report found that July 09, 2014, 3:00 p.m. ET Page 7 of 8

9 electrodiagnostic testing is an area vulnerable to fraud, waste, and abuse. This CBR is a way to educate providers and to help them identify correct billing errors. To view this OIG report, please see Questionable Billing for Medicare Electrodiagnostic Tests at pdf. ARE THESE COMPARISONS MADE BY physicians that are Board Certified Electromyographers? These comparisons were made across all types of physicians who billed the codes for electrodiagnostic studies. We would have no way of determining what additional types of certifications a physician has from the claims data we reviewed. WAS GPCI TAKEN INTO ACCOUNT IN figuring averages and comparing to specialty average? Geographic Practice Cost Index (GPCI) was not considered in this analysis. However, the report does not imply any wrong-doing on your part and you may have legitimate reasons of why your billing practices differ from the peer groups. July 09, 2014, 3:00 p.m. ET Page 8 of 8