Neurology & Pain Management Coding Alert

Counting the number of separately billable nerve conduction studies (NCS) by determining which electrodes (stimulating or recording) are moved can prove frustrating, especially because many payers still do not understand the rules for designating multiple and separately reportable studies during the same session. However, the AMA has developed an alternative (and simpler) method to determine the correct number of nerve conduction studies for 2002.

Until now, determining the proper number of NCS meant tracking the movement of electrodes during the study, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J. If either the recording or stimulating electrode remained stationary during the study, only one unit of any NCS code could be reported. If both the recording and stimulating electrodes were moved if even to a different location on the same nerve multiple NCS units could be claimed.

Note: For complete information on reporting NCS using this method, see page 33 of the May 2002 Neurology Coding Alert.

But many coders and payers not to mention auditors and others who must review claims but who may not understand the exact mechanics of NCS find the above method confusing, says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine. In addition, a lack of understanding has lead many payers to deny claims for multiple units of NCS as a duplication of services, even if the tests were conducted on completely separate nerves, or to bundle incorrectly separately reportable motor (95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study and 95903, with F-wave study) and sensory (95904, sensory) studies into a single "mixed" (95904) study.

As an alternative to counting the number of "moving electrodes," the AMA developed a list of all the nerve conduction studies that can be coded as separate procedures. A preliminary version of the list was originally published in Principles of CPT Coding, Second Edition (pages 374 and 375), and a final version of the list has just been officially released in CPT Assistant.

"I believe this will make the previous method obsolete," Busis notes. "Determining the correct number of separately billable studies should now be as simple as consulting a list." By comparing the physician's documentation against the list of separately reportable procedures, coders can easily identify the correct type and number of NCS codes to bill the studies conducted.

The AMA has arranged the list of separately reportable studies by type (motor or sensory/mixed) and location (upper extremity, lower extremity, cranial and root stimulation). Codes 95900 and 95903 describe identical procedures, except that 95903 includes F-wave study (see Neurology Coding Alert, March and May 2002 for more information). Note that studies without F-wave (95900) are bundled with studies with F-wave (95903) if both are performed on the same nerve, Jandroep says. If performed on different nerves, the studies are independently reportable. Although sensory and mixed nerve studies are different procedures, each is reported using the same code (95904).

The list of separately reportable studies is as follows (each study represents one unit of 95900, 95903 or 95904, as appropriate):

I. Upper extremity/cervical plexus/brachial plexus motor studies

A. axillary motor nerve to the deltoid
B. long thoracic motor nerve to the serratus anterior
C. median nerve

1. median motor nerve to the abductor pollicis brevis
2. median motor nerve (anterior interosseous branch) to the flexor pollicis longus
3. median motor nerve (anterior interosseous branch) to the pronator quadratus
4. median motor nerve to the first lumbrical
5. median motor nerve to the second lumbrical

D. musculocutaneous motor nerve to the biceps brachii
E. phrenic motor nerve to the diaphragm
F. radial nerve

1. radial (posterior interosseous) motor nerve to the extensor carpi ulnaris and brachioradialis
2. radial motor nerve to the extensor digitorum communis
3. radial motor nerve to the extensor indicis proprius

G. suprascapular motor nerve to the supraspinatus and infraspinatus
H. thoracodorsal motor nerve to the latissimus dorsi
I. ulnar nerve

1. ulnar motor nerve to the abductor digiti minimi
2. ulnar motor nerve to the palmar interosseous
3. ulnar motor nerve to the first dorsal interosseous
4. ulnar motor nerve to the flexor carpi ulnaris

J. other

II. Lower extremity motor nerves

A. femoral motor nerve to the quadriceps
B. peroneal nerve

1. peroneal motor nerve to the extensor digitorum brevis
2. peroneal motor nerve to the peroneus brevis
3. peroneal motor nerve to the peroneus longus
4. peroneal motor nerve to the tibialis anterior

C. sciatic nerve
D. tibial nerve

1. tibial motor nerve (inferior calcanean branch) to the abductor digiti minimi
2. tibial motor nerve (medial plantar branch) to the abductor hallucis
3. tibial motor nerve (lateral plantar branch) to the flexor digiti minimi brevis

III. Cranial nerves

A. cranial nerve VII (facial motor nerve)

1. facial nerve to the frontalis muscle
2. facial nerve to the nasalis muscle
3. facial nerve to the orbicularis oculi muscle
4. facial nerve to the orbicularis oris muscle

B. cranial nerve XI (spinal accessory motor nerve)

IV. Root stimulation

A. cervical nerve root stimulation
B. lumbar root stimulation

I. Upper extremity sensory and mixed studies

A. lateral antebrachial cutaneous sensory nerve study
B. medial antebrachial cutaneous sensory nerve study
C. median nerve

1. median sensory nerve to the second and third digits
2. median palmar cutaneous sensory nerve study
3. median sensory nerve to the third digit
4. median palmar mixed nerve study

D. posterior antebrachial cutaneous sensory nerve study
E. radial sensory nerve study

1. radial sensory nerve study to the base of the thumb
2. radial sensory nerve study to the first digit

F. ulnar nerve

1. ulnar dorsal cutaneous sensory nerve study
2. ulnar sensory nerve study to the fourth digit
3. ulnar sensory nerve study to the fifth digit

G. comparative studies

1. median and radial sensory nerves to the first digit
2. median and ulnar mixed nerve studies
3. median and ulnar sensory studies to the fourth digit

H. thoracic dermatomes
I. intercostal nerve
J. other

II. Lower extremity sensory and mixed studies

A. lateral femoral cutaneous sensory study
B. medial calcaneal sensory study
C. medial femoral cutaneous sensory study
D. peroneal nerve

1. deep peroneal sensory study
2. superficial peroneal sensory (medial and intermediate dorsal cutaneous branches)

E. posterior femoral cutaneous sensory study
F. saphenous nerve

1. saphenous sensory study (distal technique)
2. saphenous sensory study (proximal technique)

G. sural nerve

1. sural lateral dorsal cutaneous branch sensory study
2. sural sensory study

H. tibial sensory nerve study (medial plantar nerve)
I. tibial sensory nerve study (lateral plantar nerve)
J. tibial sensory nerve study (digital nerve to toe one)
K. other.

Using the above lists, coders can determine the exact number of separately reportable studies. For example, documentation lists NCS with F-wave study of the radial motor nerve to the extensor digitorum communis and without F-wave study of the radial motor nerve to the extensor indicis proprius and of the radial sensory nerve study to the first digit. The F-wave study of the radial motor nerve to the extensor digitorum communis is in section I, F2, and because it includes an F-wave study would be reported with one unit of 95903. The NCS without F-wave study of the radial motor nerve to the extensor indicis proprius is in section I, F3, and because is did not include F-wave would be reported with one unit of 95900. Because section I, E2 contains the final study of the radial sensory nerve study to the first digit, one unit of 95904 should be reported.

As a second example, documentation lists a study of the median sensory nerve to the third digit as well as a median palmar mixed nerve study. The study of the median sensory nerve to the third digit is in section I, C3, and the median palmar mixed nerve study is in section I, C4, so two units of 95904 may be reported.

Until use of the AMA's nerve chart becomes more widespread, it will be difficult to determine how payers will react and what documentation requirements they may initiate to substantiate NCS claims determined using this method. "This is a new area," Busis says. "It will be interesting to see how the list gets used."

Regardless of how payers react, the new list shou greatly ease billing for NCS. Although the list does not replace the previous method of determining separately reportable studies, it offers a more attractive alternative.