Neurology & Pain Management Coding Alert

You can kiss your -without F-wave serve conduction study (NCS)- pay good-bye unless you use these strategies to show the payer the additional study is separately payable. Take a look at this recent reader's scenario and put your nerve conductioncoding skills to the test.

A patient arrives for neuromuscular electrodiagnostic testing on his lower extremity.Your neurologist performs a study that includes a distal and proximal Peroneal nerve conduction recorded off the extensor digitorum brevis (EDB) muscle, along the foot.The late-response F-wave study is also performed. How should this be billed?

Answer: Bill the NCS as 95903 (Nerve conduction, amplitude and latency/ velocity study, each nerve; motor, with F-wave study). So far, so good.

The plot thickens: The distal compound muscle action potential (CMAP) amplitude is below normal, so your neurologist performs an additional Peroneal conduction study, recorded off the tibialis anterior muscle (TA) stimulated at the fibular head. What code should you bill for this additional test?

Answer: Your instinct may be to bill 95900 (Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study), because the set-upand testing for the motor NCS to the TA muscle is different from the motor NCS with F-wave to the EDB muscle. This instinct is correct, but if Medicare or a private payer denies 95900, secure payment with the following ammo.

If facing this Medicare denial scenario, your first line of defense is the CPT 2009 manual. -Appendix J is helpful in illustrating that these two motor nerve conduction studies are separately billable in that the two nerve branches are separate and distinct even though both are labeled with the -Peroneal- name,- advises Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver.

The Peroneal motor nerve to EDB muscle is listed as II.C.1 and the Peroneal motor nerve to the TA muscle is listed as II.C.4. These should be considered two separate and distinct nerve branches.

The beginning directions in Appendix J indicate, -Each nerve constitutes one unit of service.- A February 2008 CPT Assistant Coding Communication article further explains, -From a CPT coding perspective, as long as the testing is performed on different nerves or nerve branches on the list (Appendix J), multiple units should be reported.-

In the scenario given above, the coder overlooks using a tool to legitimately gain payment for both tests. She incorrectly appended no modifier to 95900. A modifier is necessary to indicate that the two motor NCS are performed on different nerves or nerve branches.

Correct Coding Initiative (CCI) edits bundle 95900 as a component of 95903. The bundling edit prevents providers from billing both 95900 motor NCS (without F wave) and 95903 motor NCS (with F wave) for the same nerve or nerve branch. Most commercial payers also include this bundling edit in their proprietary bundling edit software.

Exception: A modifier can bypass the CCI edit. Catch: The provider must perform a motor NCS without F wave on a separate and distinct different nerve or branch than the nerve or branch that the motor NCS with F wave was tested.

In the scenario, your neurologist performed a motor NCS with F wave on the Peroneal motor nerve branch to the EDB muscle, whereas he also performed an additional motor NCS without F wave diagnostic study on the separate and distinct Peroneal motor nerve branch to the TA muscle. This would be compliantly reported as:

- 95900-59 x 1 for the Peroneal to TA diagnostic test

- 95903 x 1 for the Peroneal to EDB diagnostic test

Modifier 59 (Distinct procedural service) explains to the payer that diagnostic motor nerve conduction studies were performed on two different nerves or nerve branches--one with an F wave study and one without.Without the 59 modifier, the payer sees that only one motor nerve was tested, initially without the F wave and then the F wave was performed--in effect reporting the base motor NCS twice.Without the modifier, typically the payer would deny 95900 as bundled and not separately payable.

In making a payer appeal for the denial, you should:

- Make sure that 59 modifier is appended to 95900 (CCI column 2 code).

- Use different colored highlighters to -illustrate- on the computer generated report the two distinct motor NCS.

- Highlight in your neurologist's documentation the medical necessity for separately performing the additional testing.

- Copy Appendix J of the CPT book and use the same colored highlighters as in the computer generated report to illustrate the two separate diagnostic studies.

- Include a copy of February 2008 CPT Assistant's -Coding Communication: Nerve Conduction Studies (95900-95904)- article if available, again noting the pertinent supporting information.