Neurology & Pain Management Coding Alert

Neurologists often encounter denials when billing for H-reflex studies because insurance carriers dont understand that the test must be performed bilaterally for purposes of comparison. But by using modifier -50 (bilateral procedure) physicians can reduce denials.

H-reflex studies are nerve conduction studies used to obtain the measurement of peripheral nerve and muscle function, including both motor and sensory nerves. Electrodes are placed on two different muscles to see how the reflexes in the muscles react to stimulation.

Debbie Stumpf, REdT, of NeuroHaven Neurology and Neurosurgery Associates, PA in Winter Haven, Fla., a registered electromyography technician with 15 years experience, submits the following example:

A patient presents with complaints of lower back pain. Upon examination, the neurologist finds that the pain shoots down into one leg, an indication that an S1 nerve root problem may exist. The physician performs a bilateral H-reflex study. Electrical stimulus is introduced in the calf, the only area in which a response can be elicited in an adult. The time it takes for the impulse to travel to the sciatic nerve and return is measured in milliseconds for both the affected leg and the unaffected leg. If the latency, or time it takes for the impulse to travel and return, is greater in the affected limb, a radiculopathy or disease of the spinal nerves may exist. The absence of any response at all in the affected limb is an even more telling sign. Further testing would then be ordered, beginning with a needle electromyogram (EMG). (For more information on EMGs, see cover article.)

Because carriers may not understand that H-reflex studies must be performed bilaterally for comparison purposes, coders who simply list the procedure code twice may find their claims denied for duplication of service. Claims also can be rejected for lack of medical necessity.

The codes for these studies are:

- 95934H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle
- 95936H-reflex, amplitude and latency study; record muscle other than gastrocnemius/soleus muscle

Cindy Dumond, supervisor at Medical Billing Services Inc. in Jacksonville, Fla., who has worked in hospital and physician billing for 15 years, says that H-reflexes have to be billed to Medicare with a -50 modifier attached to the single procedure code. The use of this modifier indicates to carriers that the study was performed on both sides and that the reimbursement should be greater.

Appropriate Diagnosis Codes and Documentation

Another important requirement for H-reflex studies to be paid is the listing of the appropriate diagnosis and the documentation of the medical necessity for the test. Many carriers require the use of specific diagnosis codes in relation to these procedures. If these codes are not used, payers may deny reimbursement for the procedure.

For example, here are the most common ICD-9 codes Medicare in Georgia considers appropriate to justify H-reflex studies:

- 724.9spinal nerve root compression
- 724.2low back pain
- 357.0polyradiculitis

Coders should contact the patients insurance company before the test is performed to determine the carriers particular coding guidelines. These guidelines may vary slightly from state to state and carrier to carrier.

If the carrier requires prior approval, the coder should send either a letter of medical necessity or the office notes from the examination before the neurologist conducts the bilateral H-reflex testing. Documentation also may be required by carriers who do not require prior approval to show the medical necessity for the procedure.

In addition, the documentation must state clearly that the tests are being performed on two different extremities. Also, the paperwork must note the individual results for each test in the paperwork.

Tips From AAEM for Flex Study Reimbursement Tiffany Eggers, JD, MPA, policy director/legislative counsel for the American Association of Electrodiagnostic Medicine (AAEM), who works with neurologists and physiatrists, reports that submitting AAEM's Recommended Policy for Electrodiagnostic Medicine with claims has helped many coders to receive speedier reimbursement for H-reflex studies. This document was prepared by the association and has been offered with their approval. It may be found with other such documents on their Web site: http://www.aaem.net. The relevant portion of the recommended policy pertaining to H-reflex studies states: Late Responses: H-Reflex and F-Wave Studies 1. Late responses are performed to evaluate nerve conduction in portions of the nerve more proximal (near the spine) and, therefore, inaccessible to direct assessment using conventional techniques. Electrical stimulation is applied on the skin surface near a nerve site in a manner that sends impulses both proximally and distally. Characteristics of the response are assessed, including latency. 2. F-wave and H-reflex studies provide information in the evaluation of radiculopathies, plexopathies, polyneuropathies (especially with multifocal conduction block or in suspected Guillain-Barr syndrome or chronic inflammatory demyelinating polyneuropathy), and proximal mononeuropathies. In some cases, they may be the only abnormal study. 3. The physicians report should identify the nerves evaluated and the F-wave and H-reflex characteristics, including latency. CPT Codes 95934 and 95936 H-Reflex Studies 1. CPT codes 95934 (H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle) and 95936 (H-reflex, amplitude and latency study; record muscle other than gastrocnemius/soleus muscle) are defined as unilateral H-reflex study codes and are intended to be reported per study. Typically, only two H-reflex studies are performed in a given examination. 2. H-reflex studies usually must be performed bilaterally because symmetry of responses is an important criterion for abnormality. When a bilateral H-reflex study is performed, the entire procedure must be repeated, increasing examiner time and effort; there are no economies of scale in multiple H-reflex testing. A bilateral H-reflex study should be reported by appending modifier -50 (bilateral procedure) to the CPT code reported or by the use of the separate 5-digit modifier code 09950. 3. H-reflex studies usually involve assessment of the gastrocnemius/soleus muscle complex in the calf (CPT code 95934). Bilateral gastrocnemius/soleus H-reflex abnormalities are often early indications of spinal stenosis, or bilateral S1 radiculopathies. 4. In rare instances, H-reflexes need to be tested in muscles other than the gastrocnemius/soleus muscle, for example, in the upper limbs. In conditions such as cervical radiculopathies or brachial plexopathies, an H-reflex study can be performed in the arm (flexor carpi radialis muscle). Other muscles that may be tested, although rarely, are the intrinsic small muscles of the hand and foot. These cases would be coded using CPT code 95936.