Neurology & Pain Management Coding Alert

Question: When reporting H-reflex studies (95934-95936), I receive better reimbursement when reporting two units of service than when appending modifier -50 for a bilateral study. Am I coding correctly?

Oklahoma Subscriber

 

Answer: No, you are not coding correctly. To describe testing on both the right and left sides, you should append modifier -50 (Bilateral procedure) to a single unit of the appropriate H-reflex code (95934, H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle; or 95936, ... record muscle other than gastrocnemius/soleus muscle). As explained in CPT (Appendix A), Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier -50 to the appropriate five-digit code. When you use modifier -50, payers generally reimburse the code at 150 percent (rather than 200 percent) of the usual fee because they consider the tests set-up cost as a part of the first tests relative value units (RVUs).
 
You should not be reporting multiple units of 95934-95936 to describe a bilateral study. This is fraudulent coding and can result in audits, fines and criminal prosecution. Contact your payers immediately to correct past mistakes. Although payers will require you to return illegitimate payments, this is far better than the alternative.