Eli's Rehab Report

Question: We had a patient for whom the doctor billed CPT 99245 (office consultation for a new or established patient) along with an electromyogram (EMG). Can we be paid when billing for both codes together?

New York Subscriber

Answer: To bill for the consultation according to CPT 2000, the patients record must document the written or verbal request for the consult, along with the consultants opinion and any services ordered or performed. In addition, the consulting physician must communicate his or her opinion to the requesting physician or other appropriate source in writing (this stipulation is new to CPT 2000; previously the consultants opinion could be reported verbally or in writing).

CPT 2000 also dictates that the physician consultant can initiate diagnostic and/or therapeutic services at the same or subsequent visit, and that any specifically identifiable procedure performed on or subsequent to the date of the initial consultation should be reported separately.

The actual performance or interpretation of diagnostic tests or studies ordered during a patient encounter is not included in the levels of evaluation and management (E/M) services. Physician performance of diagnostic tests or studies for which CPT codes are available may be reported separately, in addition to the appropriate E/M code.

Because were not sure whether you are dealing with commercial insurance, Medicare or Medicaid, we should note that some carriers (private insurance or state Medicare or Medicaid) may not allow a consultation service if certain therapeutic management procedures are done at the same time as the consultation. Be sure to check your carriers rules and the accompanying CCI edits to know whether your carrier allows the 99245 with the EMG code that you are using.

EMG (95860 - 95875) may be considered medically necessary and reasonable when performed using an ICD-9 code allowable by your insurance carrier. In the absence of symptoms the EMG would be considered screening, so its important to research the conditions that your carrier covers. EMG normally should not be repeated unless there is a documented need to evaluate the effectiveness of various treatments or there is a documented change in the patients symptoms.

Medical record documentation maintained by the physician must include the medical necessity for performing this test (including a neurological history, examination, and documentation of neurological symptomology) and EMG test results.