Neurology & Pain Management Coding Alert

Bilateral conditions may require the neurologist to forego recommended testing limits

If you're reporting multiple electrodiagnostic (EDX) tests for the same patient, you may need to submit extra documentation to support your claim.

To ensure that you are not exceeding "reasonable and necessary" limits when reporting EDX tests, consult the American Association of Neuromuscular and Electrodiagnostic Medicine's Recommended Policy for Electrodiagnostic Testing. In the minority of cases when the neurologist determines that he must exceed the AANEM's testing recommendations, she should provide supplementary documentation to justify the additional testing.

Refer to the Utilization Chart

To prevent abuse and overutilization in your neurology practice, take the time to post the AANEM's "maximum number of tests necessary in 90 percent of cases" in a prominent location in your office.

The goal of the AANEM chart is to establish a baseline for the quantity of EDX testing required for a neurologist to diagnose a given condition. Many payers have adopted this chart as a model for their medical review policies on common diagnostic studies such as electromyography, nerve conduction studies, H-reflex, and others.

The number of tests that the AANEM policy recommends 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," says Tiffany Schmidt, JD, policy director for the AANEM.

Internet resource: You can view the complete text of the AANEM Recommended Policy for Electrodiagnostic Testing at www.aanem.org.

AANEM Sets the Guidelines

In most cases, neurologists should be able to diagnose a patient properly while still meeting the AANEM recommendations.

Example 1: The AANEM Recommended Policy for Electrodiagnostic 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 AANEM policy further explains that H-reflexes and F-waves may provide complementary data to evaluate suspected radiculopathy.

Example 2: Testing guidelines for mononeuropathy differ from those for EMG. To exclude radiculopathy, plexopathy or polyneuropathy, the neurologist may have 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," the AANEM policy says.

Important lesson: "You can't test and bill indiscriminately," Schmidt says. "Overutilization and overbilling harms the patient and adversely affects reimbursement for all physicians."

Additional Testing Is OK, With Documentation

If your neurologist exceeds the maximum number of tests recommended to diagnose a given condition, don't automatically think you can't get the claim paid.
 
In a minority of cases (about 10 percent or fewer), the AANEM's recommended maximum number of tests for a given diagnosis may not provide sufficient information to evaluate the patient's condition properly.

"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 tests may be required to determine if the findings are significant."

Here are three examples of when the AANEM chart may not be enough:

Example 1: Unexplained Symptoms/2 Diagnoses

"One common circumstance is where the diagnosis found does not fully explain the patient's condition," says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine.

"For example, a patient has a numb arm, and the only thing found after lots of tests is carpal tunnel syndrome (354.0) - which doesn't explain all the patient's signs and symptoms. The number of tests allowed for CTS is far smaller than the number needed to diagnose that patient."

In this case, Busis explains that the examiner must submit two ICD-9 codes: one to describe the unexplained symptoms (e.g., numbness or weakness) and one for the CTS. "This signifies that CTS was not the whole story," he says.

"Another situation where the table falls down is when the neurologist finds multiple diagnoses," Busis says. "The text explaining the AANEM recommendations explicitly states that the table does not apply in these cases."

Example 2: 'Comparison'  Testing

Example 2: Schmidt agrees that there are numerous situations when an EDX consultant may need to perform tests not specifically ordered by the referring physician."For example," Schmidt says, "when a patient is referred with a provisional diagnosis of carpal tunnel syndrome on the right, it is frequently necessary to perform electrodiagnostic studies on the patient's left side for comparison purposes."

AANEM policy specifically notes that in some situations physicians must test "an asymptomatic contralateral limb to establish normative values for an individual patient." This is because "normal" values based on the general population are often not sensitive enough to establish a baseline. "Therefore restrictions on
contralateral asymptomatic limb testing will reduce the sensitivity of electrodiagnostic tests," the AANEM states.

Example 3: Bilateral Conditions

Unlike CPT, ICD-9 has no modifier to describe a bilateral condition, which may require additional testing, Busis says. "The numbers for unilateral and bilateral CTS in the [AANEM] table are different, but there is no way to flag the bilateral patients automatically."

Documentation tip: In this case, you will need to submit supplemental information, such as the patient note and the physician's EMG report. "If you want to dictate a separate rationale for the study, that's OK, too," Busis says.
 
Both Medicare and third-party insurers frequently state in their medical review policies for EDX testing that claims exceeding the AANEM recommendations "should be reviewed for medical necessity."

Payers will apply additional scrutiny to such claims, so the neurologist must carefully document the need for additional testing.