AAN Guideline: TENS Not Effective for Chronic Low-Back Pain

A new guideline issued by the AAN finds that transcutaneous electric nerve stimulation (TENS), a widely used pain therapy involving a portable device, is not recommended to treat chronic low-back pain pain that has persisted for 3 months or longer because research shows it is not effective. The guideline is published in the December 30 online issue of Neurology®.

The guideline also determined that TENS can be effective in treating diabetic nerve pain, also called diabetic neuropathy, but more and better research is needed to compare TENS to other treatments for this type of pain.

Senate Passes Health Reform Bill

In a 60-39 party line vote, the Senate passed the Patient Protection and Affordable Care Act in the morning on December 24.

Prior to the Senate vote, AMA President-elect Cecil B. Wilson, MD, announced the Association's backing during a Dec. 21 Capitol Hill appearance with Senate Majority Leader Harry Reid (D, Nev.) and other top Democrats. Dr. Wilson noted that the leaders had amended the bill to eliminate some earlier provisions that had prompted AMA concerns, such as a one-year Medicare pay patch that would have led to a projected 23% cut in 2011, an elective cosmetic surgery tax and a proposed Medicare enrollment fee.

But the AMA will continue to push for additional changes to the legislation during the conference negotiations. The Association, for instance, said it will not support a final House-Senate bill unless lawmakers make key revisions to: a proposed independent Medicare advisory board that could impose pay cuts on physicians, a plan to release Medicare data in the form of physician performance reports, and a requirement that doctors participate in Medicare quality reporting or face penalties.

In order to preserve AMA backing for the health system reform bill, the Association said Congress must also demonstrate that it is on track to approve separate legislation permanently repealing the Medicare physician payment formula before the current rate freeze expires at the end of February.

CMS Holds Claims and Extends Provider Enrollment

Last week Congress temporarily averted the 21.2% Medicare physician payment cut. On December 19, President Obama signed the bill which will stop the cuts until March 1, 2010. Other changes reflected in the 2010 Medicare Physician Fee Schedule final rule will still take effect on January 1, 2010 and may have a slight impact on the conversion factor used for the first two months of 2010. Similar to other years, since Congress acted so late in the year to avert the cut, CMS will hold claims for the first 10 business days of January (January 1 through January 15) for 2010 dates of service to allow its contractors time to update their systems and pay claims based on the updated rates CMS does not anticipate any cash flow problems for physicians since by law no claims are paid prior to 14 days after receipt anyway.

In addition, CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to March 17, 2010. Physicians still have time to consider their participation options with the Medicare program. Additional information can be found on the AMA's web site. The effective date for any participation status change during this extension remains January 1, 2010, and will be in force for the entire year. Medicare contractors will accept and process any participation elections or withdrawals made during the extended enrollment period that are received or post-marked on or before March 17, 2010.

AMA Supports Senate Health Reform Bill

After carefully evaluating the changes contained in the manager's amendment filed by Senate Majority Leader Harry Reid (D-Nev.), the AMA Board of Trustees voted to support passage of H.R. 3590. In a letter of support to Sen. Reid, the AMA noted the need for additional changes in the final conference committee agreement that reconciles the differences between the House and Senate bills.

The AMA Board's decision to support passage of the amended version of H.R. 3590 is consistent with the recommendation from the AMA Council on Legislation that the AMA support H.R. 3590 while seeking additional changes in the House-Senate conference committee agreement. Check the AMA website for more detailed analysis.

SGR Cut Temporarily Prevented

Yesterday the President has signed, a measure that extends the current Medicare physician payment rate for the next two months, thus blocking a 21.2 percent reduction that was scheduled to go into effect on Jan. 1 under the SGR formula.

The two-month payment patch, which was passed as part of a massive defense appropriations bill, gives lawmakers more time to replace the SGR payment formula.

House Votes to Delay SGR Cuts

This afternoon, the House passed a 2-month extension of expiring appropriations for the Department of Defense that included a 2-month extension of the sustainable growth rate (SGR). In other words, the legislation would stop the 21.2% Medicare pay cut scheduled take effect on January 1 for a period that will end March 1, 2010. The legislation does not affect any of the other payment policies included in the final 2010 fee schedule rule; those will take effect on schedule.

A cloture motion on the DoD extension bill was filed in the Senate today. Votes on cloture and passage should be completed this weekend.

AMA Morning Rounds: Early data for ALS drug candidate shows improved muscle function

The AP (12/10) reports, "Sangamo Biosciences Inc. said Wednesday that early data from a clinical trial shows its Lou Gehrig's disease drug candidate," SB-509, "improved patients' muscle function." Patients injected with the drug "were about twice as likely to have improved muscular function," according to Sangamo. Specifically, "32 percent of patients who received SB-509 had improved muscle function, compared to 17 percent of patients who took standard treatments." The company "is also testing SB-509 as a treatment for diabetic neuropathy."

HIPAA 5010 Resources for January 2012

Are you preparing for the compliance deadlines for the Health Insurance Portability and Accountability Act (HIPAA) 5010 standard transactions, the next version of HIPAA? Beginning Jan. 1, 2012, physicians will be required to use only the 5010 standard transactions when conducting them electronically. The AMA has prepared several educational resources to assist physicians with implementing the 5010 standard transactions.

AMA Morning Rounds: Findings shed light on essential tremor

In the New York Times (12/8, D7) Personal Health column, Jane Brody writes, "Recent studies have begun to unravel the mysteries of essential tremor," a condition characterized by "uncontrollable shaking...that is not due to some other condition." According to Dr. Elan D. Louis, of Columbia University, the progress is marked by "discoveries in three areas -- the brain, clinical findings, and genetics and environment." Researchers have "analyzed and compared...the brains of normal individuals" to those of patients with essential tremor, finding that "this is probably a family of diseases." Abnormal findings include "degenerative changes in the cerebellum," and "a messy arrangement of neurofilaments." Meanwhile, "two environmental toxins have been found to be elevated in tremor patients: lead and a dietary chemical called harmane that occurs naturally in plants and animals."

AMA Morning Rounds: FDA lifts clinical hold on CytRx Lou Gehrig's treatment

The AP (12/2) reported that the FDA "lifted a nearly two-year suspension on development of" CytRx Corp.'s "arimoclomol as a treatment for Lou Gehrig's disease." The agency "halted arimoclomol studies" in January 2008, "citing the need for additional analysis from previously completed animal studies with arimoclomol."

Reuters (12/2) reported that the FDA accepted CytRx's revised trial protocol to review the safety and efficacy of the experimental drug at four times the dose previously studied. The FDA has granted the drug a fast-track review and orphan drug status to treat Lou Gehrig's disease.

Texas Judge Rules EMG, MUA are Beyond Scope of Chiropractors

In a November 24th ruling, Austin State District Judge Stephen Yelenosky said state law prevents chiropractors from performing clinical needle electromyography (EMG) or spinal manipulation under anesthesia (MUA). Yelenosky granted a Texas Medical Association and Texas Medical Board request for a partial summary judgment against the Texas Board of Chiropractic Examiners and the Texas Chiropractic Association.

"Judge Yelenosky ruled that chiropractors cannot perform needle EMGs or manipulation under anesthesia because both of those procedures are beyond the chiropractors' lawful scope of practice," said Austin attorney David F. Bragg, one of the lawyers for TMA. The chiropractors are expected to appeal the ruling, he said.

TMA sued in 2006 to block the chiropractic board's rules that would permit chiropractors to perform clinical needle EMG and MUA, because both procedures constitute the clinical and legal practice of medicine. View the full press release at the TMA website.

Chemodenervation Units: 64614

I was contacted last week by a member who was denied payment by Medicare for 2 units of 64614 (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {eg, for dystonia, cerebral palsy, multiple sclerosis}) of the right arm and right leg on the same visit. He has received payment in the past for billing 2 units of service in this circumstance. The member believed that policy existed supporting side of the body application for this code. 

I have not located any information supporting a hemisphere concept for this code.  In fact, it’s just the opposite.  By defining the code use for “extremity(s) and/or trunk muscle(s),” the code language indicates that everything--whether 1 extremity or multiple extremities--is covered in 1 unit.  Additionally, a CPT Assistant Q&A from February 2005 touched on this topic. 

Q: Would it be appropriate to append modifier 50, Bilateral procedure, to CPT code 64614, Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis), if both extremities are treated at the same session?

AMA Comment: From a CPT coding perspective, modifier 50 should not be appended to CPT code 64614 because the language of the code descriptor allows for chemodenervation of muscles of single or multiple extremities, as well as muscles of the trunk, if performed. This code should be reported only one time for chemondenervation of any of these areas within a single session.

Some payors may incorrectly pay for bilateral injection reported with modifier 50. Others may incorrectly pay for 2 units of 64614. However, the correct way to bill this service is to report 1 unit of 64614 for any/all extremities and/or muscles of the trunk.

House Repeals SGR

The AMA Bulletin below provides a good summary of the bill and House actions that led to passage.

By a vote of 243-183 today, the U.S. House of Representatives passed H.R. 3961, a bill that repeals the current Medicare physician payment formula, known as the sustainable growth rate (SGR), and replaces it with a new framework. Michael Burgess, MD, (R-Texas), a former AMA alternate delegate was the sole Republican to vote for final passage.

This legislation would replace the SGR with a new formula that creates two updates: GDP +2 for Evaluation and Management services and GDP + 1 for other services. Additional technical changes will avoid the accumulation or compounding of debt that occurred with the SGR formula.

House Speaker Nancy Pelosi (D-Calif.), House Majority Leader Steny Hoyer (D-Md.), House Committee on Ways and Means Chairman Charles Rangel (D-N.Y.), House Ways and Means Health Subcommittee Chairman Pete Stark (D-Calif.), House Committee on Energy and Commerce Chairman Henry Waxman (D-Calif.), Rep. Frank Pallone (D-N.J.), the bill's sponsor Rep. John Dingell (D-Mich.), and the Obama Administration were strong advocates for passage of H.R. 3961.

House Republican leadership offered a last-minute alternative that would have provided for 2 percent updates over the next four years, reverting back to the SGR and steep cuts. Also, it would have offset the cost with medical liability reforms modeled after California and Texas laws. The AMA opposed the motion to recommit because we do not support any temporary "patches" for the SGR. A permanent repeal is long overdue. The motion to recommit with medical liability reform provisions was ruled non-germane. A second GOP alternative providing for a two-year "patch" was defeated by a vote of 177-253.

The battle now shifts back to the Senate. While action to permanently repeal the SGR was blocked in the Senate last month, the Obama Administration and several senators support a permanent replacement of the SGR formula. The health system reform bill released by Senate Majority Leader Harry Reid (D-Nev.) provides for a one-year reprieve with a steeper cut in 2011. The AMA does not support temporary patches that further grow the problem.

No one expects Congress to allow the 21 percent cut scheduled for Jan. 1 to occur. We regret that Congress has deferred action until the "eleventh hour." The AMA will redouble our efforts in the Senate and with the Obama Administration to achieve a permanent solution.

Medicare Changes for 2010

Medicare’s 2010 final rule confirms that physicians face steep cuts of 21.2% in 2010. Permanent repeal of the flawed sustainable growth rate (SGR) formula is an essential element of comprehensive health system reform. In October, the Senate failed to pass a bill (S. 1776) that would fix the problem, while the House is expected to vote soon on a different bill (H.R. 3961) that would also fix the problem.

The rule includes other changes for EDX physicians as well. A proposal for Medicare to stop accepting consultation codes (99241-99245, 99251-99255) as of January 1, 2010 was finalized and included in the rule. Physicians will instead report the office visit codes (99201-99205, 99211-99215) to Medicare for these services. For inpatients, use hospital care codes (99221-99223) or initial nursing facility care visit (99304-99306) evaluation and management (E/M) codes for the first visit during a patient’s admission to a hospital or nursing facility. In its proposal to eliminate the consultation codes, Medicare cited continued provider dissatisfaction with Medicare documentation requirements, confusion between a consultation and a transfer of care, and similarity in the physician work of consults and office visits, despite the work higher value. The AANEM and many other entities commented in opposition to this change and the fast implementation to no avail.

To maintain budget neutrality the RVUs for other office visit E/M services will be increased proportionately, about 6%. Work RVUs for hospital and nursing facility visits will be increased approximately 2%. The table below shows how the removal of consult codes and subsequent redistribution of value affects key E/M codes.

* Calculated before 21.5% SGR cut is applied. **Inpatient codes have only three corresponding levels of service.

Finally, CMS currently utilizes practice expense (PE) data and physician hours from the 1995-1999 AMA Socioeconomic Monitoring System (SMS) survey to calculate “practice expense per hour” estimation and direct to indirect cost ratio for each specialty. This data and the accompanying PE and malpractice (MP) RVUs are being updated with new survey data from 2007-2008 that was compiled through joint efforts of AMA, CMS, and over 70 national health care organizations. Implementation of these data will redistribute practice expense payment among specialties during a 4-year transition period.

Physical medicine and rehabilitation physicians will receive a 2% increase from transitional practice expense RVU changes in 2010, increasing to a 6% increase in 2013. Neurologists will receive a 1% transitional increase in 2010, culminating in a 4% increase in 2013. As part of the redistribution, a number of other specialties will see net reductions in 2010 through the 2013 transition, as seen in this table.

Neuromuscular Ultrasound Position Statement

A new position AANEM statement addressing neuromuscular ultrasound was approved in October by the Board of Directors. The position statement defines neuromuscular ultrasound, specifies uses for the technique, and lists requisite qualifications necessary to perform it. The complete position statement is available here.

Medicare Physician Payment Reform Act of 2009

Call your U.S. Representative today!

Next week, a floor vote is planned in the House of Representatives on H.R. 3961, the “Medicare Physician Payment Reform Act of 2009.” This legislation would permanently repeal the sustainable growth rate (SGR) formula that calls for annual cuts in Medicare physician payments, and replace it with a new, more rational payment system.

In less than two months, Medicare payments will be slashed by more than 21 percent because of the SGR formula. Past short-term patches have only made the problem worse. This is the time to solve the problem once and for all, to preserve access to care and provide physician practices with the financial stability they need to help build a 21st century health care system.

It is imperative that you contact your U.S. representatives today to ask that they vote for H.R. 3961.

Call (800) 833-6354, the AMA Grassroots Hotline, to be directly connected with your representative.

Tell your representative:
•Congress must fulfill its obligations to Medicare patients and military families covered by TRICARE.
•Short-term patches that only make future cuts deeper and the cost of a permanent solution more expensive are not the answer.
•The fiscally responsible solution is permanent repeal of the SGR formula.
•Vote “YES” on H.R. 3961.

Send an e-mail directly to your representative through the AMA Grassroots Action Center at www.ama-assn.org/go/grassroots.

AMA Morning Rounds: FDA extends review of neuropathic pain drug

The AP (11/10) reports that the FDA "needs three more months to review an application to a neuropathic pain drug being developed by XenoPort Inc. and GlaxoSmithKline PLC," called gabapentin enacarbil, according to the companies. The companies said the FDA "should complete its review of the drug" by Feb. 9, 2010. The AP adds, "The FDA wanted the companies to develop a strategy to evaluate the drug's risks, and after GlaxoSmithKline submitted that strategy, the agency needed additional time to review it." The Triangle Business Journal (11/9) also covered the story.

AMA House of Delegates Committed to Health System Reform

As the House of Representatives passed a health reform bill this weekend, the AMA House of Delegates is holding its Interim Meeting in Houston. Delegates have introduced a number of resolutions related to health system reform. Some are supportive of current bills and measures, while others are critical. After lengthy testimony regarding health reform in reference committee hearings on Sunday, the HOD voted on Monday to reaffirm its committment to existing health reform policies in Substitute Resolution 203, maintaining support for H.R. 3962. View resources that show exactly which proposals are supported and opposed. 

AMA President J. James Rohack, MD noted, "H.R. 3962 is not the perfect bill, and we will continue to advocate for changes that help make the system better for patients and physicians as the legislative process continues." The AMA will continue to support H.R. 3961 to repair the broken Medicare SGR formula and keep pushing for liability reforms that will reduce the costs of defensive medicine.

House Passes Health Reform Bill

The U.S. House of Representatives passed a health reform bill Saturday night by a vote of 220-215.  The Affordable Health Care for America Act (H.R. 3962) makes many changes to the current health system. The key purpose of the bill is the expansion of health coverage to the uninsured and underinsured through subsidies financed by increasing taxes on high earners ($500,000 individual, $1,000,000 married filing jointly) and cutting costs in the current system. The Congressional Budget Office predicts the 10-year cost of these changes is $1.054 trillion. The bill does not make significant changes to medical liability laws or address the flawed Medicare SGR formula.

Senate leaders have been working to complete their own version of a health refrom bill that will be different from the House bill. If the Senate is able to pass a bill, then members from both chambers will have to reconcile the two different bills into a single bill that would then have to pass both chambers.

FTC Delays Red Flag Rules 3rd Time

The Federal Trade Commission recently announced its third delay in implementation of the Red Flags Rule. Implementation of the rules has been delayed until June 1, 2010. The AMA has been urging the FTC and Congress that physicians are not "creditors" and should not be subject to the rule. View the FTC's release for more information on the delay.

The AANEM encourages its members to be cognizant of these rules and will continue to report on anticipated implementation and the work of the AMA on this issue. The AMA has developed resources for implementation of these rules.

Highmark Corrects Max. Number of Studies Table

Through the efforts of AANEM's State Liaison in New Jersey, Dr. Alexander Pendino, Highmark Medicare Services has corrected the Maximum Number of Studies Table included within its local coverage determination. Highmark was notified during the comment period in February that the table it included was not accurate and should be modified. Dr. Pendino spoke with Dr. Eileen Moynihan, Medical Director at Highmark Medicare, and discussed the inaccuracy. The modifications were not included when the new policy was released in earlier this year. Ultimately, Dr. Pendino's persistence resulted a recent correction of the table.

New CPT® Header for NCS Codes

During discussion of how tests performed with preconfigured electrode arrays should be reported, the AANEM and others agreed it would be helpful to separately identify and define nerve conduction tests in the 2010 CPT® codebook.  A new header for "Nerve Conduction Tests" was added to complement the addition of 95905. Nerve conduction studies (NCSs) previously did not have their own introductory language.  The new header provides the following introductory information:

The following applies to nerve conduction tests (95900-95904): Codes 95900-95904 describe nerve conduction tests when performed with individually placed stimulating, recording, and ground electrodes. The stimulating, recording, and ground electrode placement and the test design must be individualized to the patient’s unique anatomy. Nerves tested must be limited to the specific nerves and conduction studies needed for the particular clinical question being investigated. The stimulating electrode must be placed directly over the nerve to be tested, and stimulation parameters properly adjusted to avoid stimulating other nerves or nerve branches. In most motor nerve conduction studies, and in some sensory nerve conduction studies, both proximal and distal stimulation will be used. Motor nerve conduction study recordings must be made from electrodes placed directly over the motor point of the specific muscle to be tested. Sensory 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, 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 nerves. Reports must be prepared on site by the examiner, and consist of the work product of the interpretation of numerous test results, using well-established techniques to 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 values, summarization of clinical and electrodiagnostic data, and physician or other qualified health care professional interpretation.

Code 95905 describes nerve conduction tests when performed with preconfigured electrodes customized to a specific anatomic site.

Addition of this comprehensive definition will help physicians, coders, and payors to determine the appropriate code to report physician work. This definition clarifies several important points. (1) Testing should be limited to those nerves necessary to address the clinical question being investigated; standardized, screening tests are not the same as carefully designed NCSs and do not entail the same physician work. (2) Waveforms must be reviewed on site. (3) Reports must be prepared on site.

Motor Nerve Conduction Studies

One of the most frequent coding questions that comes to the office is how to correctly report CPT® codes 95900 and 95903. Code 95900 describes a "Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study. Code 95903 describes a "Nerve conduction study, amplitude and latency/velocity study, each nerve; motor, with F-wave study.

So as you can see, by definition, 95900 is a component of 95903 when performed on the same nerve. They should not both be billed to report study of a single nerve, e.g., median nerve to the abductor pollicis brevis. If you do report both of them, insurance companies will assume that you are trying to unbundle the service and report some of the work twice. This is true if both 95900 and 95903 are billed for studying the median nerve to the APB.

However, many payors follow this rule absolutely, and will bundle any instance of 95900 that is reported with 95903.  This is also not correct. The codes are defined per nerve, and it is appropriate to report a unit of 95900 for one nerve and a unit of 95903 for another. To avoid improper bundling, add modifier 59 to 95900. This indicates the 95900 is distinct from 95903, and should prevent payors from incorrectly bundling together study of two different nerves.

For example, a member emailed me just this week to confirm that it is correct to report 95903 for a motor with F-wave study of the peroneal nerve to the extensor digitorum brevis as well as 95900 for a motor study without F-wave of the peroneal nerve to the tibialis anterior. His analysis is correct, and he would report the first study with 95903 and the second with 95900-59.

Refer to the AANEM List of Nerves for further guidance on what constitutes a nerve. This resource has also been included in the CPT® codebook since 2006 as Appendix J. Each nerve in the list constitutes one unit of service, and can be reported as such.

Vote on SGR

Wednesday's vote to limit debate and proceed to consideration of legislation (S. 1776) to repeal the SGR, erase the existing debt, and freeze physician payments at current rates for 10 years failed. This was a disappointing blow to physicians and supporters. A majority of senators from both parties agree the formula is flawed. The vote seems to have failed because (1) moderate senators who agree the SGR is a problem could not overlook the deficit implications and (2) Senate Republican leadership portrayed this as a test vote on Democrats' health reform legislation.

Unfortunately, temporary fixes that override the formula simply make the problem worse. In 2005 it would have cost $48 billion over 10 years to repeal the formula. Physicians that year faced cuts of 3.3%. Today it would cost $245 billion and the 2010 scheduled cut to physicians is 21.5%. Visit the Health System Reform website to stay current on this and other reform issues.

New H1N1 Resources

The AMA has put together new, free H1N1 patient management tools. The website includes information for both patients and providers, including a unique online practice management system and self-assessment tools from AMA and CDC. Additional H1N1 resources are also available from the AMA.

New CPT® Code to Report Preconfigured Electrode Array Nerve Conduction

Opening the 2010 CPT® codebook for the first time last week, I was pleased to see the final publication of new code 95905. This new code will be used to report nerve conduction tests performed using preconfigured electrode arrays. Use of preconfigured arrays and highly automated devices has been a controversial issue between EDX specialists and primary care physicians for years. The AANEM and a number of other specialty societies spent long and difficult hours working to develop a coding solution that correctly describes this new and different service. The addition of 95905 appropriately distinguishes the new service from traditional NCSs.

Physicians who perform nerve conduction testing with preconfigured electrode arrays should now report code 95905: “Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report.” Parenthetical instructions further direct that, by definition, 95905 should be reported once per limb, and that 95905 should not be reported in conjunction with 95900-95904 or 95934-95936.

Members are encouraged to share this coding memo with colleagues and coders to facilitate correct use of the new code. You can print, save, or link to the memo here.

Blog Policies--Read before posting

Thank you for participating in the AANEM Blog – Action Potential. The AANEM has created this blog to share communications that come into the department regarding coding, payor coverage policies, the State Liaison Program, news headlines, and draft documents. Through the blog posts, AANEM members may post comments and dialog about a blog entry. When posting comments on the Blog, please comply with the Content Standards. By submitting your contribution to the Blog, you warrant that your post fulfills the Content Standards. You also agree that you are solely responsible for the content of your messages and that you will not hold AANEM responsible for any claim based on your post.

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Medicare Physicians Fairness Act of 2009

Contact your senators in support of S. 1776. With the introduction in the U.S. Senate of S. 1776, the "Medicare Physicians Fairness Act of 2009," earlier this week, the AMA urges all physicians to contact their senators and tell them to support this critical piece of legislation that would eliminate Medicare's sustainable growth rate (SGR) formula.

S. 1776 will be the subject of a cloture vote in the coming days. The Senate needs 60 votes to invoke cloture to allow formal consideration of the bill. A vote on final passage is expected to occur late next week, either on Oct. 22 or 23. Senate Majority Leader Harry Reid (D-Nev.), Senate Finance Committee chairman Max Baucus (D-Mont.), and Sen. Chris Dodd (D-Conn.), along with President Barack Obama, are all strongly supporting passage of S. 1776.

Send an e-mail to your senator, or call the AMA grassroots hotline at (800) 833-6354 and be connected directly to your senators' offices. Learn more about S. 1776 in the latest edition of the AMA's Health System Reform Bulletin.

AANEM Endorses AAN Guidelines on ALS

The AAN announced the publication of two new evidence-based guidelines on caring for patients with ALS today. The AANEM endorsed both documents in advance of their publication in the journal Neurology. 

The first guideline addresses drug, nutritional, and respiratory therapies. The second guideline examines the benefits of multidisciplinary care, symptom management, and cognitive/behavioral impairment.  Additional resources, including two clinician summaries, two patient summaries, a slide presentation, a clinical example, and a podcast, were also created for the guidelines  

H1N1 CPT Code

With both seasonal influenza and H1N1 influenza circulating this flu season, the AMA announced this week it has expedited the publication of a new code specific to vaccine administration and revised existing code 90663 to include the H1N1 vaccine. The new Current Procedural Terminology (CPT®) code issued by the AMA will streamline the reporting and reimbursement procedure for physicians and health care providers who are expected to administer nearly 200 million doses of the H1N1 vaccine in the United States. In consultation with the U.S. Department of Health and Human Services, the AMA CPT® Editorial Panel created code 90470 to report H1N1 immunization administration and counseling. Code 90663 was revised by the CPT® Editorial Panel to refer specifically to the H1N1 vaccine product. Both are effective immediately.

HIPAA Breach Notification Rule

New regulations effective September 23, 2009 require all physicians who are covered by HIPAA to notify patients if there are breaches of security involving their medical information. The linked guidance from the AMA summarizes the new requirements. These requirements apply in addition to any notification obligations imposed by state law. These requirements also supplement the obligations imposed by the HIPAA Privacy and Security Rules.

AMA Morning Rounds: Neuromuscular Electrical Stimulation My Help Bed-Ridden Patients

The Los Angeles Times (9/21, Stein) "Booster Shots" blog reported, "The wasting away of muscle tissue can be a serious problem for people who are hospitalized and confined to bed due to a critical illness." But, a team at Johns Hopkins discovered, through meta-analysis, that "by putting patients through neuromuscular electrical stimulation and having them do simple exercises (some with the aid of devices), muscles can be shored up, speeding recuperation and getting people back on their feet." According to the paper published in Critical Care Medicine, the group also "developed a special walker that helps severely ill patients move around more easily, and with fewer helpers."

Reporting H-reflex

The coding manager for a member in Tennessee called me this afternoon with a denial from Cahaba, the new A/B MAC in the state. The two units of 95934 were denied because the number of units exceeded medical necessity. When Dorothy called and spoke to a provider rep. at Cahaba, she was told this was because of a national Correct Coding Initiative (CCI) edit. This isn't entirely correct, as there is no CCI edit for 95934. However, there is a Medically Unlikely Edit (MUE) for 95934. An MUE of one unit has been created for 95934. I recommended that Dorothy try to resubmit one unit with modifier 50. The CPT codebook directs that bilateral H-reflex be reported using modifier 50. Hopefully this will result in reimbursement at 150% of a unilateral study.

I have encountered some variability in the way payors want to see H-reflex studies reported.

• Some consistenly reimburse for two units without a modifer, even though the CPT codebook directs that bilateral studies be reported with modifer 50.
• Some will reimburse for two units when reported with modifier 50.
• Some will reimburse 150% of one unit when reported with modifier 50.
• Some will reimburse for one unit when reported with modifier 50.

The technically correct way to report bilateral H-reflex is to add modifier 50 to a single unit. This SHOULD result in reimbursement that is roughly 150% of a single unit. However, due to variability among payors and their claims editing software, you may have to find which of the above options works through trial and error.