Eli's Rehab Report

Update Practice Systems:

Autonomic Testing Codes Are No Longer Bundled

Published on Fri Mar 01, 2002

Designed to test whether a patient suffers from nerve disorders, the autonomic nervous system testing codes (95921-95923) are often denied by Medicare because they are incorrectly bundled, or thought to be incapable of being billed together. In reality, the CCI Edits that previously bundled the tests were deleted, but many carriers have not updated their systems. Also, these codes can be billed concurrently, provided that the physiatrist performs each test individually, and that an appropriate ICD-9 code is assigned to the claim. Following are the most significant reimbursement facts regarding these diagnostic codes.

One Unit of Service Per Autonomic Testing Code

"The most important point is that you can only bill one unit of service per autonomic testing code per day, but you can bill several together if necessary," says Daniela Sigel, office manager for Robert Sigel, D.O. in Washington, D.C.

For instance, a patient is referred to the PM&R practice for autonomic nervous system testing to confirm cervical sympathetic dystrophy (337.0). The physiatrist performs an EMG (95860-95872) and nerve conduction studies (95900-95904), but still cannot make a firm diagnosis, so he or she reschedules the patient to return for sudomotor autonomic nervous system testing. During the test, the physiatrist performs a sweat imprint of the patient's hands, and has him or her perform hand grip strength testing.

Some practices believe it is acceptable to bill for three units of 95923 (Testing of autonomic nervous system function; sudomotor, including one or more of the following: quantitative sudomotor axon reflex test [QSART], silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential) for this session, since two sweat imprints were taken and a hand grip strength test was performed. However, says Sigel, this is incorrect.

"No matter how many tests you perform in the sudomotor category, you can only bill one unit of 95923," she says. "That's why the code says 'includes one or more of the following,' because you only have to perform one of the tests listed in the code, but you are allowed to perform more; it all gets billed as one unit."

This rule remains the same for 95921 (Testing of autonomic nervous system function; cardiovagal innervation [parasympathetic function], including two or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio) and 95922 (Testing of autonomic nervous system function; vasomotor adrenergic innervation [sympathetic adrenergic function], including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least five minutes of passive tilt). Each autonomic nervous system testing code can only be billed once per day per patient.

"It makes sense because these codes pay well, compared to some other testing codes," says Sigel. "You can't expect to bill 95923 and collect over $100, and then bill another unit and collect more."

Code 95921 normally pays about $65 ($15 for the technical portion, and $50 for the professional component), while 95922 pays about $70 ($15 for the technical component and $55 for the professional), and 95923 brings in about $135 ($85 for the professional component and $50 for the technical). If your practice performs both aspects of the code (professional and technical), you can expect to be reimbursed the full amount; otherwise you will be paid only for the portion you perform.

In that case, you would bill the code with modifier -TC (to indicate that you performed only the technical component) or modifier -26 (to indicate that you performed only the professional component of the test) along with the appropriate autonomic testing code. In some cases, the physiatrist performs both aspects of the code, but does not own the testing equipment. In that case, the physiatrist can bill only the professional component, and the entity that owned the equipment (e.g., the hospital) would code the technical portion.

Multiple Tests OK

The caveat to this rule is that physiatrists who perform more than one type of autonomic nervous system test on the same patient can bill two separate CPT codes on the same day. For instance, if the physiatrist tests parasympathetic function, and later in the day, tests the patient's sympathetic adrenergic function, he or she can bill both 95921 and 95922, as long as both tests were medically necessary and matched the ICD-9 codes listed on the state carrier's policy.

Some coders, however, may still face frustrating denials when billing more than one autonomic nervous system testing code for the same patient on the same day. This stems from a prior CCI edit that bundled the codes together, indicating that they were mutually exclusive. However, this edit was deleted with the CCI published on October 1, 2001, and was made retroactive so that even claims for services performed prior to that date wouldn't be affected by the problematic CCI edit.

The dilemma, however, is that many carriers haven't updated their systems to correct the error. "This is a chronic problem," says Tom Dean, CCS, president of Ocean Billing in Annapolis, Md., which handles the billing for seven medical practices. "A CCI edit is deleted and forgotten, but the insurer continues to deny claims based on that edit. If this happens, write an appeal letter, and include a copy of the CCI edits that affect your code. Let them know that they are denying claims that should be paid, and tell them which claims you would like reprocessed."

Supervision Requirements

In April 2001, CMS released program memorandum B-01-28, which outlined the supervision requirements for more than 700 diagnostic testing codes, including those for autonomic nervous system testing. The supervision rules apply to these codes when two different people are performing the technical and professional components if the physiatrist performs both components, he or she does not require additional supervision. However, if another member of the practice is performing the technical portion of the autonomic system tests, the following supervisory guidelines apply:

Code 95921 must be performed under the direct supervision of the physician in the office setting, which means that the physiatrist must be present in the office suite and immediately available to furnish assistance and direction throughout the procedure. The physiatrist does not, however, have to be present in the room as the test is taking place.

Codes 95922-95923 require the physiatrist's personal supervision, which means that the physician must be in the room while the procedure is performed. Even if another member of the staff is actually performing the autonomic system function test, the physiatrist must also be in the room with them.

Acceptable Diagnoses

As with all CPT codes, the diagnoses that link to payment for autonomic system testing vary by carrier. However, below is a sample of the codes accepted by Nationwide Medicare, the Part B carrier for Ohio and West Virginia:

250.60-250.63 Diabetes mellitus with neurological manifestations (Note: the autonomic testing codes are not covered for simple periodic monitoring of asymptomatic diabetic patients; coverage only applies if neurologic manifestations are present).

333.0 Shy-Drager syndrome

337.0-337.9 Disorders of autonomic nervous system

340 Multiple sclerosis

354.4; 355.71 Causalgia

358.1 Myasthenic syndromes (Eaton-Lambert)

458.0-458.1 Hypotension

780.2 Syncope and collapse

780.8 Hyperhidrosis

785.0 Tachycardia (postural).

Remember to check your carrier's requirements before billing any of the tests to avoid unnecessary denials.