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 [...]