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.

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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