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.