Neurology & Pain Management Coding Alert

Since distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy (as reported in a January 2009 Muscle & Nerve article), it's crucial you stay up to date on the most common tests, procedures, and diagnoses you-re likely to encounter in your neurology practice.

-DSP does not currently have a -one size fits all- evaluation, although our guidelines do offer an evidence based medicine best practices approach to the problem,- says Laurence Kinsella, MD, FAAN, a professor of neurology in St. Louis.

Your neurologist may perform some or all of the diagnostic evaluation, depending upon his training and expertise. When coding for a patient being tested for DSP, there are several procedures to look out for in the documentation.

-In the practice parameters, we recommend that all patients with DSP have a complete medical history, neurological examination, and electrodiagnostic testing (EMG/NCS) to document the presence and type of DSP,- says John D. England, MD, a professor and department head of neurology of the LSUHSC School of Medicine in New Orleans.

By following these recommendations, your neurologist should have guidelines for selecting the appropriate tests in the evaluation of DSP. These guidelines should increase the diagnostic accuracy of physicians and result in the most appropriate evaluation and treatments for patients with DSP, England says.

Consider these codes for neuromuscular electrodiagnostic testing for DSP:

- 95860-95864 -- Needle EMG - extremities

- 95867-95968 -- Needle EMG - cranial nerve supplied muscles

- 95869 -- Needle EMG - thoracic paraspinal muscles (excluding T1 or T12)

- 95870 -- Needle EMG - limited study (excluding thoracic paraspinal or cranial nerve supplied)

- 95934 -- H-reflex - gastrocnemius/soleus muscle

- 95936 -- H-reflex - muscle other than gastrocnemius/solus muscle

- 95937 -- Neuromuscular junction testing.

Or these NCS codes for testing:

- 95900 -- Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study

- 95903 -- ... motor, with F-wave study

- 95904 -- ... sensory.

Be sure to review the -Maximum Number of Studies- table at the end of Appendix J, says Marianne Wink, RHIT, CPC, ACS-EM, with the University of Rochester Medical Center in New York. -The numerals represent the number of studies recommended for a diagnosis. For example, the table indicates that in 90 percent of patients with a final diagnosis of polyneuropathy, providers would need to perform four units of motor nerve conduction [95900 or 95903] studies and four units of sensory nerve conduction studies [95904],- she adds.

Buzz word: Additionally, remember to check your payer guidelines for using modifier 59 (Distinct procedural service) when billing multiple NCS. A neurologist or specially trained physiatrist plays a critical role in the selection and performance of these tests. These are the physicians that have special training and expertise in the evaluation of DSP using these neuromuscular tests. Most patients being evaluated for DSP should have an evaluation with a neurologist.

In selected cases, neurologists recommend genetic tests, autonomic tests, and skin biopsy, England says. Skin biopsy is a valid technique to determine intraepidermal nerve fiber (IENF) density, and may be considered for the diagnosis of DSP, particularly small fiber sensory neuropathy (SFSN).

Skin biopsy is readily available, easy to perform, and can be done in the office setting, Kinsella says. The most common technique involves a punch biopsy of skin from the leg. When a section of skin is excised for biopsy the codes are as follows:

- 11100 -- Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

- +11101 -- each separate/additional lesion (List separately in addition to code for primary procedure).

DSP has many forms and causes with the most common being diabetes. Other common causes are alcohol abuse, poor nutrition, and genetics. DSP can also result from an allergic disorder, when the immune system mistakenly attacks healthy tissue in the body. Depending upon if your neurologist establishes the cause of DSP, the following are commonly used ICD-9 codes:

- 356.2  -- Hereditary sensory neuropathy

- 356.4  -- Idiopathic progressive polyneuropathy

- 356.8 -- Other specified idiopathic peripheral neuropathy

- 357.1 -- Polyneuropathy in collagen vascular disease

- 357.2  --- in diabetes

- 357.3 -- - in malignant disease

- 357.4 -- -in other diseases classified elsewhere

- 357.5 -- Alcoholic polyneuropathy

- 357.6 -- Polyneuropathy due to drugs

- 357.81 -- Chronic inflammatory demyelinating polyneuritis (CIDP).