Orthopedic Coding Alert

Coders can streamline nerve conduction study (NCS) claims by reporting multiple NCS units only if the orthopedist repositions both the stimulating and receiving electrodes from one nerve location to another.

Orthopedic practices should not report both 95900 (Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) and 95903 (... with F-wave study) for the same nerve during the same visit because 95903 includes both services.

Orthopedists often use NCS to diagnose specific conditions, such as carpal tunnel syndrome (354.0). Physicians usually test several nerves, often using a combination of tests, to determine how many nerves are involved. For instance, the orthopedist performs a motor NCS on a patient's hand without an F-wave, then rotates the hand and performs an F-wave test on the same nerve.

According to Tiffany Schmidt, JD, director of policy for the American Association for Electrodiagnostic Medicine (AAEM), "CPT codes 95900 and 95903 should not be reported together for the same nerve in the same visit, as CPT code 95900 is a component of CPT code 95903." She reminds practices, however, that these studies may be performed on separate nerves on the same patient.

Schmidt advises practices to use the following guideline to determine whether the orthopedist studied an additional nerve: "If either the recording or the stimulating electrode remains stationary when multiple nerve conduction studies are performed, then only one unit of 95900-95904 may be billed. If both the recording and the stimulating electrode are moved to different locations, then the orthopedist may bill for both 95900 and 95903."

In addition, Schmidt says, the April 2002 CPT Assistant published a list of nerves to assist coders when determining what constitutes separate nerves. The list is also available on the AAEM Web site at www.aaem.net.

Gillian Knight, office manager at Knight Orthopedics in Denver, recommends appending modifier -59 (Distinct procedural service) when submitting claims for both 95900 and 95903. "One of the insurers we use does not require modifier -59, but another carrier denies 95900 when we submit both codes, even if two different nerves are addressed. So we just made a routine of always using it with this type of claim."

Schmidt advises practices that file claims with both 95900 and 95903 to submit a written report with the claim to indicate which tests the orthopedist performed on which nerves.

In addition, she says, some Medicare carriers require modifier -59 to indicate that the orthopedist addressed separate nerves. "Although this may work for reimbursement, it is technically not 'correct coding,' " Schmidt says. "95900 and 95903 are to be billed per nerve by definition (with no modifier needed), yet payers do not recognize this and reject them on a regular basis." She recommends appending modifier -59 to 95900 instead of 95903 because most insurers will reject the claim for 95900 and pay only 95903.

Medicare and other payers frequently state in their NCS medical review policies that claims exceeding AAEM recommendations "should be reviewed for medical necessity." In other words, the carriers imply that they will apply additional scrutiny to such claims and that orthopedists must be ready to justify the need for additional testing. To aid physicians, the AAEM developed a table that lists the "maximum number of tests necessary in 90 percent of cases." The number of tests varies according to the suspected conditions or diagnoses.

For example, the AAEM Recommended Policy for Electrodiagnostic Medicine states that a minimal evaluation for radiculopathy (729.2) "includes one motor [95900] and one sensory [95904] NCS and a needle EMG [electromyography] examination of the involved limb [95860]" but that testing can include "up to three motor NCSs (in cases of an abnormal motor NCS, the same nerve in the contralateral limb and another motor nerve in the ipsilateral limb can be studied) and two sensory NCSs." The AAEM policy further notes that H-reflex (95934) and F-wave (95903) tests may provide complementary data to evaluate suspected radiculopathy.

Orthopedists must be cautious not to bill NCS tests too frequently for the same patient. For instance, Aetna U.S. Healthcare's coverage policy bulletin for NCS states, "Utilization of nerve conduction studies at a frequency of two sessions per year would be considered appropriate for most conditions (e.g., unilateral or bilateral carpal tunnel syndrome, radiculopathy, mononeuropathy [355.9], polyneuropathy [356.9], myopathy [359.9] and neuromuscular junction disorders). Nerve conduction velocity studies performed more frequently than twice a year should be reviewed for medical necessity." Be sure to get your insurer's frequency guidelines in writing before treating a patient with NCS.