Neurology & Pain Management Coding Alert

Neurologists reporting H-reflex studies should append modifier -50 (bilateral procedure) to the appropriate code to indicate to the carrier that bilateral testing is necessary. In addition, carriers often specify, and strictly enforce, a limited number of diagnoses to support these tests. Failure to append the modifier, or use of improper ICD-9 codes, will result in claim delays and denials.

H-reflex testing measures and records amplitude and latency of muscles and may be used to diagnose nerve damage or disease (e.g., spinal stenosis or radiculopathy), says Tiffany Z. Eggers, JD, MPA, policy director/ legislative counsel for the American Association of Electrodiagnostic Medicine (AAEM) in Rochester, Minn. These tests can provide useful complementary information to evaluate a suspected radiculopathy and provide additional electrodiagnostic information to support a diagnosis although in some cases they may be the only abnormal study performed. CPT specifies two codes to report these procedures, depending on the muscle(s) tested:
  

95934 H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle
  

95936 ... record muscle other than gastrocnemius/soleus muscle.

Code 95934 should be used when the muscles of the lower leg (i.e., the calf muscle) are tested. Code 95936 applies to any other tested muscles, e.g., the flexor carpi radialis, in the arm. The intrinsic small muscles of the hand and foot may sometimes, although rarely, be tested and should also be reported with 95936, Eggers says.
 
When performing an H-reflex study, the neurologist looks for an abnormal muscle response. To establish a "baseline" measurement, he or she will perform the test on each side of the patient's body and compare the response of the "unaffected" to the "affected" muscle. According to information available on the AAEM Web site, "H-reflex studies usually must be performed bilaterally because symmetry response is an important criterion for abnormality."
 
Note: The AAEM Web site (www.aaem.net) contains a "Recommended Policy for Electrodiagnostic Medicine" that provides additional information on H-reflex studies and other electrodiagnostic tests.
 
Laureen Jandreop, OTR, CPC, CCS-P, CPC-H, consultant-owner and trainer for A+ Medical Management and Education in Egg Harbor City, N.J., offers the example of a patient who complains of shooting pain and/or numbness in the right leg. The neurologist tests the patient via an H-reflex study. He or she first tests the left calf muscle to find the normal response for that patient, then checks for variation by testing the right calf. A delayed or nonexistent response on the affected side of the body may indicate nerve damage.
 
CPT descriptors for 95934 and 95936 specify "muscle" rather than "muscles" and as such AAEM and Medicare consider these to be unilateral codes. Therefore, when the tests are performed on both sides of the body, the appropriate H-reflex study code should be reported with modifier -50 or the five-digit modifier 09950 attached, Eggers says. In the above example, the neurologist would report 95934-50 (or 95934-09950) for his or her services. Typically, two H-reflex studies are performed per examination.
 
Note: Some Medicare carriers want bilateral claims listed on two lines, as follows:
 

95934
 

95934-50
 
Check with your local carrier for its preference prior to billing for these services.

Physician documentation should note that testing was performed on two limbs and identify the nerves evaluated and the H-reflex characteristics, e.g., latency.
 
Do not report 95934 (or 95936) x 2 to report bilateral testing, or the claim will be denied for duplication of services. No modifier should be applied if only one limb is tested, Jandreop notes.
 
Check Your Payment

Claims filed with modifier -50 should be reimbursed at a higher rate to reflect the increased physician time and effort required, Jandreop says. According to local medical review policy (LMRP) #152, of Cahaba GBA, the local Medicare carrier in Georgia, "Codes 95934 and 95936 have a Medicare Physician Fee Schedule Data Base (MFSDB) bilateral surgery indicator of '1.' [A] 1 indicates that a 150 percent payment adjustment for bilateral procedures applies." Other carriers follow the same guidelines and will reimburse bilateral procedures at 150 percent of the rate applied to a unilateral procedure.
 
Note: The Physician Fee Schedule assigns 95934 1.03 relative value units (RVUs), or about $39, according to the national average conversion rate, while 95936 is assigned 0.80 RVUs, or about $31. Upon receiving payment for bilateral H-reflex tests, be sure to check that the proper amount, i.e., 150 percent of the unilateral fee, has been paid. If the payer has not reimbursed accordingly, appeal the claim.

Like other nerve conduction studies (NCS), H-reflex tests must be performed directly by a physician, or a trained individual under the direct personal supervision of a physician. As explained in Blue Cross/Blue Shield North Dakota's (the local Medicare carrier for Colorado, North Dakota, South Dakota and Wyoming) LMRP #96.21C, "Direct personal supervision means that the physician is in close physical proximity to the electrodiagnostic laboratory while testing is under way, is immediately available to provide the trained individual with assistance and direction and is responsible for selecting the appropriate NCSs performed."
 
Note: H-reflex studies may be performed by a physical therapist who is certified by the American Board of Physical Therapy Specialists as an electrophysiological clinical specialist and if he or she is permitted to provide the service under state law.
 
Some insurers require prior approval for these tests. Therefore, always contact the payer before performing an H-reflex study because a letter of medical necessity or office examination notes may have to be filed first. Also, most insurers limit the number of such tests that can be provided within a given time. For instance, Cahaba GBA LMRP #152 dictates, "Repeat testing within a 12-month period will be denied as medically unnecessary unless accompanying documentation justifies additional testing."
 
An appropriate ICD-9 code must be provided to establish medical necessity for such diagnostic testing, Jandreop warns. Here again, individual payer requirements may vary. Ask the insurer which diagnoses it will accept to support a claim for H-reflex studies (see sidebar).