Neurology & Pain Management Coding Alert

Despite MEG's technical advantages, inconsistent and generally inadequate reimbursement policies have delayed its widespread use. For example, under the 2002 OPPS guidelines, the facility fee for 95965, 95966 and 95967 came to only $150 not enough to justify the expense of the equipment and necessary staffing, etc. In addition, pending further research, Part B Medicare payers and some third-party payers have adopted policy decisions that deny coverage for MEG as an investigational procedure.

Continued lobbying by the American Academy of Neurology (AAN) and the National Association of Epilepsy Centers, however, has resulted in increased facility fees for MEG under OPPS. Effective Jan. 1, 2003, payment for the technical portion of 95965, 95966 and 95967 rises to $2,250, $1,375 and $875 respectively (for increases of 483-1,400 percent), and therefore more Medicare beneficiaries will likely have access to the technology (note that Medicare provides payment under OPPS only payment in the outpatient setting is carrier-priced). And according to VSM Medtech Ltd., a manufacturer of MEG equipment, more than 200 private insurers now routinely reimburse for MEG scans.

Neurologists would employ MEG in two main instances, Barkley says: for epilepsy localization prior to surgery and for presurgical functional mapping. In the first case, the likely code combination is 95965 and three or more units of 95967, as supported by documentation. For presurgical functional mapping of several functions using MEG (for example, auditory, optical and somatosensory), report a combination of 95966 and two or more units of 95967 again, as supported by documentation. Note that 95967 is an add-on code for use with 95965 and 95966 only for each additional modality beyond the first (for example, for two modalities, report one unit of 95965/95966 and one unit of 95967; for four modalities, report one unit of 95965/95966 and three units of 95967, etc.).

Because insurers have not adopted a standard reimbursement policy for MEG, ask your payer for its guidelines prior to billing (note that managed-care programs will almost always require preauthorization). The payer may maintain a list of diagnoses for which MEG is justified or may provide special documentation instructions. As always, get the payer's recommendations in writing.

The physician may employ MEG in combination with other studies, including EEG (95812-95827), evoked potential studies (somatosensory, auditory or visual, 92585, 95925-95930), computed tomography (CT) scans (70450-70470, 70496) and most frequently magnetic resonance imaging (MRI, 70551-70553). CPT instructs coders to report these procedures in addition to the appropriate MEG codes. Modifier -51 (Multiple procedures) and multiple-procedure payment reductions do not apply to such diagnostic procedures.

You may report an E/M service on the same day as a diagnostic testing only if the E/M service meets the definition of modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). That is, the E/M service must be above and beyond that usually associated with MEG or other testing. Acursory exam and discussion does not qualify. You need not link a separate diagnosis to the E/M procedure (conceivably, for instance, the E/M service prompted the testing, and therefore the same diagnosis applies to both), but you may wish to physically separate documentation for the E/M service to further emphasize its separately identifiable status.