Neurology & Pain Management Coding Alert

Tip: Be careful of which codes you can submit together. 

Each code for autonomic testing has specific requirements before you can bill it, which means you need to know details regarding descriptors, medical necessity, and more. The following three steps will help you cover all the bases for whichever code you submit. 

Starting point: Autonomic testing evaluates a patient’s physiologic responses to various stimuli, which investigates the degree of dysfunction in a particular part of the nervous system. The procedures don’t test for a specific disease, but can help the neurologist narrow the differential diagnosis and possibly make a clear diagnosis.. 

Step 1: Break Down the Descriptors 

The descriptors for codes representing autonomic nervous system testing and related tests include many details to help you narrow the choices to the correct code. Start by getting an overview of all the options: 

• 95921 – Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio 
  
• 95922 – … vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least 5 minutes of passive tilt 
  
• 95923 – … sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential 
  
• 95924 – … combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt
  
• 95943 – Simultaneous, independent, quantitative measures of both parasympathetic function and sympathetic function, based on time-frequency analysis of heart rate variability concurrent with time-frequency analysis of continuous respiratory activity, with mean heart rate and blood pressure measures, during rest, paced (deep) breathing, Valsalva maneuvers, and head-up postural change. 
  

Automated note: Autonomic testing using automated devices (using software to automatically generate an interpretation) has not been validated. No automatic devices currently in use are sufficient for billing the services associated with 95921-95924 (when the automatic test is used alone). If your provider uses automated devices for the testing, the only appropriate code choice is 95943. 

Step 2: Know Which Codes to Report Together – or Not 

As with many CPT® procedures, the codes for autonomic nervous system testing include notes that outline whether you should report the codes together. Consider these examples: 

• Only report 95924 when the physician tests both the parasympathetic and adrenergic functions with a tilt table. 
• If the autonomic function testing does not include beat-to-beat recording or the use of a tilt table, report 95943. 
• Do not report 95922 in conjunction with 95921. 
• Do not report 95924 in conjunction with 95921 or 95922.
• Do not report 95943 in conjunction with 93040, 95921, 95922, or 95924. 

Step 3: Double Check the Diagnosis for Necessity

Most payers, including Medicare, have specific criteria before autonomic function testing will be considered medically necessary. For example, Blue Cross Blue Shield of Mississippi’s policy states that autonomic function testing, “may be considered medically necessary for use as a diagnostic tool to evaluate symptoms of vasomotor instability after more common causes have been excluded by other testing.” A few of the payer’s example scenarios include: 

• Diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a progressive autonomic neuropathy
• Evaluate and treat patients with recurrent unexplained syncope to demonstrate autonomic failure
• Diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient 
• Evaluate change in type, distribution or severity of autonomic deficits in patients with autonomic failure. 

Research shows that quite a few disorders can impair the function of the autonomic nervous system. Always check the policy for the payer in question, but the following disorders might require autonomic nervous system testing and be approved by the payer: 

• Chagas’ disease (086.x) 
• Lewy body disease (331.82) 
• Parkinson’s disease (332.x) 
• Cerebellar ataxia (334.x) 
• Idiopathic autonomic neuropathy (337.xx) 
• Guillain-Barré syndrome (357.0) 
• Orthostatic hypotension (458.0)
• Sicca syndrome (710.2) 
• Syncope (780.2) 
• Tachycardia (785.0) 

Remember: A vast number of medications may influence autonomic test results, and physicians who perform autonomic testing must be aware of the potential for misinterpretation of results in that context.