Neurology & Pain Management Coding Alert

Nerve conduction studies (NCS) are becoming a problem for neurology coders looking for reimbursement. Carriers are denying many claims, citing "not medically necessary," "not proven to be effective," or "experimental and investigational" reasons. But don't give up. Here's how your neurologist can get the reimbursement he's due.

As technology continues to improve, many non-neurologists -- including primary care physicians (PCPs) -- are using testing machines and coding their use as nerve tests. This practice has raised red flags with many payers, including Blue Cross/Blue Shield (BCBS), United Health Care (UHC) and Medicare, making neurology reimbursement harder to obtain.

Watch out: "The problem we have had is that these doctors do their -neurological testing- on the patient, bill and collect for same, and then, if there is a neuro problem, want to send the patients to us to treat," says Kristina Westberry, with Affiliated Neurologists in Goodlettsville, Tenn. This can cause treatment and billing problems for your neurologist.

For example: Dr. Smith, a PCP, performs a "preliminary" NCS on a patient, and bills code 95904 (Nerve conduction, amplitude and latency/velocity study, each nerve; sensory). Dr. Smith sends the patient to Dr. Jones, a neurologist. Dr. Jones conducts a diagnostic NCS and bills the same code. Unfortunately, the payer refuses to reimburse Dr. Jones, stating that the NCS for this patient has already been paid. On the other hand, Dr. Jones doesn't want to treat a condition without verifying the test results himself.

The NCS codes at the center of the controversy include the following:

- 95900 -- Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study

- 95903 -- . . . motor, with F-wave study

- 95904.

Look for EMG: These NCS codes do not include the use of electromyography (EMG), which can make all the difference. "Recently, some Medicare carriers, Blue Cross and others have said they will only reimburse for NCS if performed in conjunction with an EMG and only when performed by a physician specialty trained in electrodiagnostic testing, such as a neurologist or physiatrist," Westberry says. No one should have problems being reimbursed if they bill for NCS along with an EMG performed by a neurologist, and they adhere to recommended units by diagnosis, Westberry adds.

Other carriers have adopted similar policies. Cigna, for example, says an EMG must be performed with NCS in order to be covered. UHC has similar policies.

A UHC FYI: According to UHC, the company will reimburse for NCS (95900, 95903-95904, 95933-95934, 95936-95937) and EMG (92265, 95860-95861, 95863-95870, 95872), when you report such codes with one of the diagnosis codes listed in the Nerve Conduction Studies/Electromyography Policy. This policy went into effect in November 2006.

Diagnosis code examples include 250.6X (Diabetes with neurological manifestations . . . ), 335.20 (Amyotrophic lateral sclerosis) and 357.82 (Critical illness polyneuropathy), among many others.

Double-check guidelines: To meet the recommended units by diagnosis requirement, refer to CPT Appendix J, which gives the "reasonable maximum number of studies" for NCS and EMG. "If the [neurologist] performs more than the recommended number of studies, make sure they record sufficient documentation in case you need to appeal," says Michele Dufore of Lake Norman Neurology in Mooresville, N.C.

Refer to your state Medicare local coverage determination (LCD) for EMG and NCS to make sure the ICD-9 and CPT codes are within the medically necessary guidelines. "My rule of thumb is to stay within Medicare guidelines for all the insurance companies we send claims to," Dufore says. And notify your neurologist that staying within the CPT guidelines for maximum number of studies reduces claim denials.

For example: To determine if a patient has unilateral carpal tunnel syndrome (CTS), your neurologist conducts electrodiagnostic testing (such as nerve conduction studies, 95900, 95904 and/or extremity needle electromyography). The table in CPT Appendix J provides a reasonable maximum number of studies for a physician to arrive at a diagnosis in 90 percent of patients with that final diagnosis. The table indicates for unilateral CTS, a maximum number of NCS on three motor nerves, four sensory nerves and a single-needle EMG study. If the diagnostic studies are conclusive for CTS, you would report 354.0 (Carpal tunnel syndrome) as the primary diagnosis.

The bottom line is that there is a world of difference between screening and diagnosing.

Screening: A physician of any stripe may conduct a nerve screening with a machine that tests sensory and/or mixed nerve latencies but not motor NCS. Such machines do not include an EMG. Another machine tests amplitude of response at sensory roots as an indication of the source of radicular pain. 

Diagnostic: Neurologists, however, "test motor and sensory nerves both distally and proximally, in addition to watching motor reflexes through the spinal cord at various levels up the cord," Westberry says. This is not a screening tool, but rather a diagnostic study, which makes it eligible for reimbursement.

There are several codes recommended in the CPT manual (Appendix J) when coding EMG studies: 95860-95864, 95867-95870 and 95934-95937. These codes are tests, not screening, and you may bill them if the neurologist adheres to recommended units by diagnosis in Medicare local coverage determinations.

Note: For more information on correctly coding NCS (95900, 95903, 95904), check out Neurology Coding Alert, Vol. 10, No. 7.