Neurology & Pain Management Coding Alert

When conducting electrodiagnostic (EDX) tests, neurologists must be cautious not to exceed the allowable number of procedures that an insurer will recognize to confirm a given diagnosis or differentiate between possible diagnoses. By following the American Association of Electrodiagnostic Medicine's (AAEM) recommendations and communicating with payers, neurology practices can minimize claim denials and accusations of abuse or overutilization. How Much Is Enough? Although each patient is unique, physician advocacy groups and insurers agree that there is a reasonable limit to the number of diagnostic studies (e.g., electromyography, nerve conduction studies, H-reflex) necessary to confirm or differentiate a given diagnosis(es). "You can't test and bill indiscriminately," warns Tiffany Schmidt, JD, policy director for the AAEM. "Overutilization and overbilling harms the patient and adversely affects reimbursement for all physicians."

To aid physicians and coders in preventing abuse and overutilization, the AAEM has developed a chart listing the "maximum number of tests necessary in 90 percent of cases" (see page 75), to which many insurers look when designing medical review policies. The number of tests varies according to the suspected condition(s) or diagnosis(es). "In simple, straightforward cases, fewer tests will be necessary. This is particularly true when results of the most critical tests are normal," Schmidt explains. For instance, the AAEM Recommended Policy for Electrodiagnosic Testing states that a minimal evaluation for radiculopathy "includes one motor and one sensory NCS [nerve conduction study] and a needle EMG [electromyography] examination of the involved limb" but that testing can include "up to three motor NCSs (in cases of an abnormal motor NCS, the same nerve in the contralateral limb and another motor nerve in the ipsilateral limb can be studied) and two sensory NCSs." The AAEM policy further notes that H-reflexes and F-waves may provide complementary data to evaluate suspected radiculopathy. Testing guidelines for mononeuropathy, for example, differ: To exclude radiculopathy, plexopathy or polyneuropathy, the policy notes, "It may be necessary to study three motor and three sensory nerves including the clinically affected nerve, the same nerve on the contralateral side and an unaffected ipsilateral nerve. F-wave studies provide additional diagnostic information. A needle EMG examination in the affected limb is indicated." Note: You can view the complete text of the AAEM Recommended Policy for Electrodiagnosic Testing, along with the associated chart, online at www.aaem.net. Sometimes More Is Better In a minority of cases (about 10 percent or fewer), the AAEM's recommended maximum number of tests for a given diagnosis may not provide sufficient information to properly evaluate the patient's condition. "In very complex cases, the maximum numbers in the table will be insufficient for the physician to arrive at a complete diagnosis," Schmidt says. "Also, in cases where there are borderline findings, additional [...]