Neurology & Pain Management Coding Alert

Shore up your diagnostic testing claims, medical necessity in 2004

You've assigned the right code to an electro-myography (EMG) or other diagnostic test, confirmed that the neurologist's interpretation is in the file, and clipped the ordering physician's EMG order to the patient's chart. Another pristine chart guaranteed to bring your practice quick payment, right? Maybe not: If a physician who is excluded from the Medicare program ordered the diagnostic test in the first place, Medicare and other federal payers won't reimburse you for your work.
 
Specifically, the U.S. Office of Inspector General's (OIG's) 2004 Work Plan states, "Under Federal regulations, physicians who are excluded from federal healthcare programs are precluded from ordering, as well as performing, services for Medicare beneficiaries. During a current review, we identified a significant number of services that had been ordered by excluded physicians."
 
Neurology practices simply can't afford to have scores of diagnostic testing services denied just because an ordering physician was excluded from the Medicare program - and this is particularly frustrating when physicians don't self-disclose that they are excluded.
 
So how can you credential your facility's ordering physicians? The OIG maintains a database of excluded physicians. You can either download the entire database or search it using physician or business names. To access the database, visit http://oig.hhs.gov/fraud/exclusions.html.

Documenting Medical Necessity Is Necessary

In 2004, you'll need to work even harder than before  to verify medical necessity for all services and tests, particularly nerve conduction studies, because the OIG will be looking carefully at medical necessity. Indeed, the plan states, "We will assess the medical necessity of diagnostic tests, such as nerve conduction studies, performed by physicians ... Medicare-allowed amounts for nerve conduction studies increased from $136 million in 2000 to $186 million in 2001 - approximately 37 percent." The OIG also plans to focus on medical necessity for E/M services.
 
Generally, demonstrating medical necessity is a function of complete and accurate ICD-9 coding, such as providing all relevant primary and secondary diagnoses, reporting sign and symptoms codes to justify testing, using E codes and late effects to describe causes, and linking diagnoses directly to their corresponding procedure codes. "The information in the physician's documentation should substantiate any diagnosis he or she selects when ordering diagnostic tests," says Bruce H. Cohen, MD, co-director of the Brain Tumor Center at the Cleveland Clinic Foundation in Cleveland.
 
For example, a diabetic patient with suspected neuropathy visits the neurologist for diagnostic testing. During the exam, the patient reveals signs and symptoms (such as 787.02, Nausea; 787.01, ... with vomiting; 787.03, Vomiting; 789.06, Abdominal pain, epigastric, etc.) that suggest gastroparesis (536.3), a neuropathy-related gastrointestinal disorder. For a diabetic, gastroparesis is especially serious. Oral medications may never reach the bloodstream. Insulin injections become impossible to schedule because the patient cannot predict when or if meals will be digested, increasing the risk of hypo- and hyperglycemia.
 
Assessing all the criteria of history (comprehensive), exam (comprehensive) and MDM (high complexity) for the above, the service qualifies as a level-five office visit (99205, Office or other outpatient visit for the evaluation and management of a new patient ...). Appropriate ICD-9 coding is crucial, however: Without a primary diabetes diagnosis (such as 250.9x, Diabetes with unspecified complication), signs and symptoms such as vomiting and nausea cannot substantiate a high level of risk to the patient, and therefore cannot provide medical justification for an extensive E/M service. By the same token, an established diabetes diagnosis, without signs and symptoms of potentially serious complications, does not warrant a comprehensive history, detailed exam and high- complexity MDM.

Apply Modifier -59 With Caution

The OIG also intends to "determine whether claims were paid appropriately when modifiers were used to bypass National Correct Coding Initiative (NCCI) edits." Although several modifiers - including -78 (Return to the operating room for a related procedure during the postoperative period) and -79 (Unrelated procedure or service by the same physician during the postoperative period) - can separate bundled NCCI edits, neurologists usually use modifier -59 (Distinct procedural service) to report two separate (but usually bundled) services provided on the same day.
 
For example, NCCI bundles 95900 (Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) to 95903 (... motor, with F-wave study). However, if the physician performs a nerve conduction study (NCS) without F-waves at the same time as but on a different nerve than (such as ulnar rather than median) an NCS with F-waves (for instance, during diagnostic testing for carpal tunnel syndrome), 95900 may be billed in addition to 95903. But you must apply modifier -59 to the former code (in other words, the component code) to indicate a separate anatomic location.
 
Physicians should be aware that when they append modifier -59, they are indicating that they have documentation on file that supports using it, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. "Therefore, you should always be prepared to submit additional documentation that demonstrates that your procedures were separate and distinct from one another." If your documentation can't prove the separate nature of the bundled services, don't append modifier -59, she adds.
 
The OIG Work Plan includes information about all of its investigative focus areas for 2004. You can access the full 90-page document by visiting the OIG's site at http://oig.hhs.gov. Search for "2004 Work Plan."