Neurology & Pain Management Coding Alert

When billing electromyograms (EMGs) (95860-95870) make it clear to carriers through detailed documentation that the complex criteria for reimbursement have been met. Use codes judiciously and correctly to attain optimal reimbursement.

Technical and Professional Components

If your practice is charging for both the technical and professional components of EMGs, documentation must support this claim. The EMG must be done in the office using equipment owned by the practice for the technical component to be billed. Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., explains that the patients chart notes must reflect not only what tests were done but on how many muscles and which and how many extremities, etc. The professional component includes a detailed interpretative report from the physician that specifies his or her findings. Simply recording the test results is not sufficient for proving the professional component; the chart note must explain what the test results mean.

Callaway says that if the technical component of the EMG was done somewhere other than the practice, in a hospital for example, it must be reported with modifier -26 (professional component). This indicates that the physician performed the interpretation only and will result in a fee reduction of 50 percent or more.

Billing an E/M with EMG

According to a sample of local medical review policies (LMRPs), if a neurologist bills for a consultation (99241-99245) in addition to EMG services, the referring source has to clearly request a medically necessary consultation service. This must be done in writing, which can be appended to the patients medical record to document this as well as the test. Additionally, the referring source must meet all the other criteria for a consultation:

Referral from primary physician;
Report sent to primary physician; and
Recommendations for patients care.

If the doctor bills for an initial or established office visit (99201-99205, 99211-99215) with an EMG, there needs to be documentation in the patients medical record that the visit met all three evaluation requirements (history, exam and medical decision-making), rather than the short history, assessment and muscle examination that all neurologists perform prior to EMGs.

Whichever E/M code is chosen, some coders recommend submitting it with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached because the EMG is a separate service performed on the same day as the E/M.

Reporting EMG Results

When billing for an EMG, Dianna Hofbeck, RN, CCM, AFCE, president of North Shore Medical Inc., a medical billing and case management company in Absecon, N.J., recommends sending these claims in hard-copy form (versus electronically) with all documentation to the insurer at the outset of the process. Let the payer know why you should be paid. If you do this on your first claim submission, you wont have to appeal. This method has worked for us for over 30 years of billing, Hofbeck says.

Documentation that should be sent varies from carrier to carrier. Some require the neurologists chart notes as well as diagrams of where the tests occurred and any dictation associated with the claim. Others want EMG reports that document the muscles tested and explain the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials. A final diagnosis, which in some cases, may be a symptom or a normal diagnosis, should also be included.

Documentation should always include the following:

A clinical history from the referral source that clearly explains the need for each test;

A copy of the progress notes with the pertinent history, presenting symptoms, and procedure report;

The raw data; and

The neurologists interpretation.

You should also consult your carrier regarding any additional information that they may need. Some will
want to see the medical-necessity documentation. Neurologists should also note any problems or additional areas of concern that developed during the testing. If these problems need to be addressed with later treatment, the doctor should already have documented them.

Occasionally our company 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, reports 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. Get either a letter of medical necessity or the office notes from the referring physician prior to performing the test.

(Note: This is the second of a two-part series. See part one on page 25 of the April Neurology Coding Alert.)