Eli's Rehab Report

H-reflex studies are almost always performed bilaterally, but the code itself is based on a unilateral test. Therefore, those practices that do not append modifier -50 (Bilateral procedure) to 95934 (H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle) may be missing out on significant reimbursement.

Physiatrists performing bilateral H-reflex studies should append modifier -50 when both calves are tested, rather than simply billing two units of CPT 95934 . Many physiatry coders are unaware of this because some carriers' policies lack this information.

"In the past, my understanding was that 95934 was a bilateral procedure, meaning that if only one side was tested, a reduced-service modifier should be added," says Kathie Davis, CPC-H, a biller at Metropolitan Hospital in Grand Rapids, Mich. "But then someone pointed out to me that it is a unilateral code, so we weren't sure whether it should be coded as two units or with a bilateral modifier."

Although the descriptor for 95934 does not specifically say that it should be coded per muscle tested, it does refer to "muscle" instead of "muscles," and, therefore, it is considered a unilateral code. "When we perform the H-reflex, it is almost always bilateral," says Deb Lachemeier, billing manager at the Spine and Pain Center PC, a one-physiatrist practice in Bismarck, N.D. The test is performed bilaterally because the physiatrist uses one side as a baseline to determine what is normal for that patient, and compares it to the results from the other side, which is where the patient has problems. Practices should review their claims to determine if they are billing these codes bilaterally, since adding the modifier will increase the reimbursement.

Some insurers' coverage policies actually remind coders to bill the H-reflex study bilaterally. Aetna U.S. Healthcare's policy states, "H-reflex studies usually must be performed bilaterally because symmetry of responses is an important criterion for abnormality."

For instance, suppose a 53-year-old patient presents with shooting pain down his left leg. The physiatrist performs an H-reflex study on the patient's right leg to obtain a normal response, then tests the left leg to find any variations. A delayed or nonexistent response on the left side of the body may indicate that nerve damage is present.

There are, of course, those practices that maintain an "If it isn't broken, don't fix it" mentality when billing for H-reflex studies and say they will continue billing 95934 x 2 units. But those practices are either being underpaid, because their carriers may simply deny the second unit for duplication of service, or being overpaid and are receiving 200 percent of the code's value for the second side, whereas they should be recouping only 150 percent with modifier -50. If that is the case, they may have to reimburse the payer for any amounts they have been overpaid, which could amount to a large sum for many physiatrists.

Occasionally, physiatrists perform H-reflex studies on muscles other than the calves. In these rare instances, the practice should report 95936 (H-reflex, amplitude and latency study; record muscle other than gastrocnemius/ soleus muscle). For instance, suppose a 43-year-old female patient presents with right shoulder weakness and numbness in her right fingers. The physiatrist suspects cervical radiculitis and performs H-reflex tests on both flexor carpi radialis muscles. The practice would report 95936-50, including documentation with the claim to indicate the exact muscles that were tested.

Some insurers require prior authorization for H-reflex tests. Therefore, PM&R practices should always contact the payer before performing H-reflex studies because a letter of medical necessity or office examination notes may have to be filed first.