Neurology & Pain Management Coding Alert

Interpreting electromyograms (EMG) results can be complex. Consequently, coding for this procedure can cause billing problems that may lead to audits. Clearly documenting the studys results and medical necessity should ensure maximum reimbursement.

Neurologists use EMGs to provide a medical diagnosis by studying the electrical properties of skeletal muscles, but they may face problems when billing for the procedure. For example, a patient complains of pain originating in the neck that shoots down her right arm and is diagnosed with cervical radiculitis (723.4). The neurologist orders several tests, including nerve conduction studies and a needle EMG. The nerve conduction studies consist of a median and ulnar sensory (95904 two units) and a median and ulnar motor (95900 two units). The needle EMG (95860) is then performed.

Kim Bunch, REDT, senior EMG technologist, Department of Neurology, Medical College of Georgia in Augusta, Ga., explains that neurologists use EMGs to provide a medical diagnosis based on the recording and study of the electrical properties of skeletal muscle. The needle EMG, for example, is an invasive procedure using needles with electrodes to measure nerve and muscle function that may assist in the diagnosis of neuromuscular conditions. Use of a needle EMG also may assist in the diagnosis of neuromuscular conditions. A basis for the diagnosis is formed during the performance of the test when the data is collected and interpreted. A needle EMG examination is not performed in the same way on every patient but is tailored to the symptoms and signs of the patient undergoing the examination.

In addition, Bunch says, the sounds and waveforms produced by a needle EMG examination must be interpreted as they occur in real time. Although the raw data collected during a needle EMG provides information used to make a diagnosis. There are other significant factors, which include:

1. the exact location of the EMG needle electrode insertion sites in the patients body;

2. the auditory output of the electromyograph during the examination; and

3. the correlation between the recorded waveforms and the patients effort during voluntary muscular contraction.

Additional history and physical examination performed on a patient by the physician can often change the diagnosis or scope of the tests, Bunch notes.

Because interpreting the results of an EMG is complex, billing problems often develop that could lead to audits. Claims may not be paid because the EMG report was not sent with the claim, the tests medical necessity was not shown, the carrier may view the performance of more than one EMG on a patient as a duplication of services, or the carrier may claim that the person who performed the procedure was not properly trained.

Documentation of EMG Results Is Critical

Cindy Dumond, who has worked in hospital and physician billing for 15 years and is a supervisor at Medical Billing Services Inc., a third-party billing service in Jacksonville, Fla., says that the report submitted to the carrier should include both the raw data and the neurologists interpretation. When an EMG is performed, a numeric reading prints out from the machine, and the technician or neurologist will write down the range and time that spikes occur. This is the raw data that should be sent with the conclusion or interpretation.

The carrier should be consulted regarding what kind of report they expect to receive. Some will want to see only the medical necessity documentation and are not concerned with the additional reports. Others will want not only the raw data, the interpretation and the medical necessity but also the case notes used to decide to perform an EMG.

Also, neurologists should note any problems or additional areas of concern that develop during the testing. If these problems need to be addressed with later treatment, the neurologist already will have documented them in the report.

Proving Medical Necessity

Dumond reports that her company occasionally has been forced to go back to the referring physician who requested the EMG and tell them they are not getting paid because the insurance carrier wants to see the medical necessity. Get either a letter of medical necessity or the office notes from the referring physician prior to performing the test, says Dumond.

Debbie King, reimbursement specialist for Neurology Specialists for Southwest Florida, Diplomates of American Board of Neurology in Ft. Myers, Fla., explains, You must be careful to have the correct diagnosis. If the carrier does not see that the diagnosis requires an EMG then they will not allow it.

Other problems arise when EMGs must be performed more than once on the same patient. For example, an initial test may be done in December and performed again in February. Carriers may impose a limit on the number of tests that the neurologist may perform for the same diagnosis within a certain period of time. The neurologist should submit a letter of medical necessity or the office notes with clear documentation explaining the need to perform the EMG again. Usually, neurologists perform this test more than once to chart the patients progress during a course of treatment. In this case, the carrier will expect to see the patient showing improvement over this period.

CPT 2000 changes to EMGs

CPT 2000 includes several new codes for EMGs. The definition of CPT code 95870 has been changed. This code involves electromyography of limb and axial muscles and is a branch code of 95869, which did not change in 2000.

Previously, these codes were defined as:

- 95869needle electromyography; thoracic paraspinal muscles

- 95870needle electromyography; other than paraspinal (e.g., abdomen, thorax)

In CPT 2000, 95870 is described as needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles or sphincters.

This code was changed to clarify its definition because most carriers previously only reimbursed 95870 when the abdomen and thorax were involved. Now, it can be used for limited EMG studies in a single limb or in some non-limb (axial) muscles. Thoracic paraspinal, cranial nerve supplied muscles, and sphincters have their own codes and should not be billed using 95870. Also, do not bill 95870 in conjunction with 95860 (needle EMG, one extremity), 95861 (needle EMG, two extremities), 95863 (needle EMG, three extremities) or 95864 (needle EMG, four extremities).