CPT Code Resequencing

I don't believe CPT's resequencing initative altered any codes that are used for EDX studies. Here is a short summary in case members encounter it in other aspects of their practice.

Instead of deleting and renumbering codes in order to display related codes together, resequencing allows adjacent placement of related concepts in the codebook regardless of the availability of code numbers for numerical placement. This change allows for greater code continuity over time and creates more options for future growth and flexibility of content.

Resequenced codes are noted with a # symbol in their new, out-of-sequence location. References have been placed numerically throughout the codebook at codes' previous locations that direct users to the out-of-sequence code. Appendix N also contains a list of resequenced codes.

Further CMS Guidance on Consultation Services

MLN Matters® SE1010 provides further clarity from CMS for those who who perform initial E/M services previously reported by CPT consultation codes for Medicare beneficiaries and submit claims to Medicare MACs for those services. The document follows a Q&A format. It includes the first information I have seen from CMS regarding low-level inpatient consultation codes 99251 and 99252. A question on page 3 asks how services previously reported with these codes should be billed since they do not meet key requirements for 99221-99223.

CPT Publishes Guidance for Consultation Coding

CPT just released an informational memo addressing consultation services and transfer of care. Much of the memo will not apply for Medicare patients since CMS is no longer accepting consultation codes. The memo suggests that Medicare contractor websites are the best place to locate further coding inforamtion for Medicare patients.

Unfortunately, a lack of direction from CMS to contractors has resulted different solutions for reporting low-level inpatient consultations. Until more specific guidance from CMS is given, adhere to the key elements of the service provided when selecting the appropriate code. For example, level 3 inpatient consultation (99253) requires detailed history, detailed exam, and low complexity decision making. This matches exactly with level 1 inpatient hospital care (99221), which requires detailed history, detailed exam, and low complexity decision making.

Limited Study EMG: 95870

Parenthetical directions below code 95870 refer users to 95860-95864 when reporting a complete study of an extremity(s). It's not always clear what this means. I have heard from some members who want more information regarding what constitutes a complete study versus a limited study, and when to use the limited code in general.

First, the language of the code 95870 is helpful. "Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters." Study of thoracic paraspinal muscles T2-T11 is reported using 95869. Study of cranial nerve supplied muscle(s) is reported with 95867 (unilateral) or 95868 (bilateral). Study of sphincters is reported with 51785-51792. Additiaonlly, oculoelectromyography is reported with 92262. Finally, laryngeal and diaphragm muscles are also not reported using the limited code becasue they have separate codes, 95865 and 95866 respectively.

Second, five muscles have to be examined to report needle EMG study of a limb. CMS provided specific guidance for codes 95860-95864 in its Final Rule for 1998 on page 59090. “To bill these codes, extremity muscles innervated by three nerves (for example, radial ulnar, median, tibial, peroneal, femoral, not sub branches) or four spinal levels must be evaluated, with a minimum of five muscles studied.” Use this standard for all EMG coding as it is now universally accepted.

If EMG testing fails to meet the five muscle standard described above and cannot be reported using a code for other anatomic sites, report limited needle electromyography code 95870. When appropriate, multiple units of 95870 can be reported for limited study of two, three, or four extremities. It may be necessary to add modifier 59 to additional units of 95870 with some payers.

Needle Electrode Expense

Occasionally I am contacted by a member who wants to know if it is possible bill for the needle electrodes that are used to perform EMG. It is incorrect to report this supply separately becasue it is already included int he value of the procedure code.

Some of these people have tried reporting HCPCS supply code A4215: Needle, sterile, any size, each. I suspect that most of the communication I get on this topic comes after a denial when someone tries A4215 for the first time, because people usually ask if they can bill for the needle, then they ask, "What about A4215?" There may be providers who bill separately for needle electrodes without any problems, but it is technically incorrect and could raise issues in the future during an audit or chart review.

Medicare Consultation Coding: MLN Matters MM6740

Medicare released a Medicare Learning Network bulletin last month that provides additional guidance on billling patient visits instead of consultations. This change regulatory change was discussed in an earlier post when first finalized in November.

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.

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.

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.

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.

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.

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.