Neurology & Pain Management Coding Alert

Question: My neurologist preformed EMGs in a hospital setting on four different patients. Three of them had Medicare and one had Wisconsin Medical Assistance. I billed them as an EMG and each insurer denied the charge because the insurer doesn't pay for EMGs at that place of service (hospital). How do I get paid for the extra time spent with these patients and for the EMG?

Wisconsin Subscriber

Answer: You need to report the corresponding CPT code with modifier 26 (Professional component) appended, which indicates you are billing only for the professional component. The insurance should process this portion of the diagnostic study without difficulty as long as the service meets any medical necessity or other payer coverage requirements.

Technical portion: As for the technical portion of these diagnostic studies, if your neurologist indeed provides not only the computer and supplies but also performs the tests -- that is, provides all the technical component of the study -- the physician needs to look to the facility for reimbursement for this portion of the services. It is best if this can be discussed and reimbursement agreed upon prior to the diagnostic studies being performed.

Medicare and some other payers process reimbursement for facilities based on the patient's diagnoses during the hospital stay, called Diagnosis Related Groupers (DRG). In that method, the facility receives payment that includes allowances for the technical component of all diagnostic studies. This includes even the technical component of EMG and nerve conduction studies that are performed by an independent physician with his own equipment, meaning the physician brings the computer and equipment, actually performs all of the technical component, and also provides the professional interpretation component. Medicare and these other payers will not and cannot allow separate payment to the physician for the technical component as they are already including the allowance for the technical portion of any diagnostic study in the facilities- payment.

Is time a component? Time would only be a component if your neurologist was also providing an E/M service in which either the majority of the time was spent in counseling and/or coordination of care or prolonged E/M service. The time spent performing the diagnostic studies is not included in the total time calculation.