Part B Insider (Multispecialty) Coding Alert

Submit extra documentation to override AANEM guidelines

Myth: Think your patients can never have more than the recommended number of electro-diagnostic (EDX) tests? You could be in for a surprise.

Appendix J of the CPT 2006 book included guidelines for how many EDX tests a physician can provide in different cases. The guidelines were developed by the American Academy of Neuromuscular & Electrodiagnostic Medicine in 2002.

For example, for a patient with "pain, numbness or tingling (unilateral)," the limit is one needle electromyography, three motor nerve conduction studies with or without f/wave, four sensory NCS or two
H-reflex tests.

Problem: If you provide more than the recommended number of EDX tests for a particular patient, your Medicare carrier or other payors may deny the extra tests as not medically necessary. But in some cases, a patient may need more tests than the AANEM guidelines call for.

For example, the physician may rule out a particular problem, such as carpal tunnel syndrome (CTS), but still be unable to diagnose the condition. A patient might also have more than one problem, or a problem that worsens quickly.

"The information in the table indicates the types of studies, or maximum number of studies, to arrive at a diagnosis in 90 percent of the patients with that final diagnosis," says Marvel Hammer with MJH Consulting in Denver, CO. If your patient falls into the 10 percent who need more tests, your documentation should explain the necessity for those tests.

Your documentation should say something like, "Due to borderline diagnostic findings of median nerve conduction on the symptomatic right side, I elected to test the patient's asymptomatic left median nerve," Hammer notes.

One carrier's policy: Florida Medicare, for example, has established a policy on repeat NCS tests, notes neurology coder Jodi Dickie. The carrier says repeat NCS testing may be medically necessary for a patient with "worsening signs and symptoms" or a new trauma or injury to the affected area. The carrier will also cover repeat tests for a patient who is being "managed medically" but isn't showing signs of improvement "using current prescribed modalities."

Tips: If your physician provides extra EDX tests, don't use a modifier, advises Ingrid Harrington with The Billing Office in Costa Mesa, CA. Use up to two ICD-9 diagnosis codes for each claim line item, to provide more information about the patient's condition. Include a note in the "comments" field asking the carrier to review your enclosed documentation.

Separate E/M: In some cases, a patient may require an evaluation & management (E/M) service on the same date as EDX tests, and a 1999 policy statement from the AANEM says the carriers should pay for those E/M services.

For example, another doctor may refer a patient for a neurologic or physiatric consultation, and during the E/M visit the consultant decides EDX testing is necessary. Also, a patient may come in for EDX testing, but have an unrelated problem that requires an E/M service. A patient also may require some evaluation to determine which areas to test, and which tests to perform.