You Be the Coder:
EMG or NCS?
Published on Thu May 01, 2003
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: Our physiatrist marked 95860 (Needle electromyography; one extremity with or without related paraspinal areas) on a superbill, but he documented the following services in the patient's chart: "Motor nerve conduction study with F-wave to ulnar sensory nerve study to the fourth digit; median sensory nerve to the third digit; radial sensory nerve study to the first digit; peroneal nerve; and H-reflex study right side, gastrocnemius." Did he code this patient's chart properly?
Utah Subscriber
Answer: Your suspicion is warranted he did not code the chart correctly. One unit of 95860 (Needle electromyography; one extremity with or without related paraspinal areas) describes a needle electromyography (EMG) study of the muscles in one extremity. Your physician, however, documented nerve conduction studies (NCS), which differ from EMGs.
Because your physician performed F-wave studies on four separate nerves, you should report four units of 95903 (Nerve conduction, amplitude and latency/ velocity study, each nerve; motor, with F-wave study). In addition, the physiatrist performed a unilateral H-reflex study, so you should also report 95934 (H-reflex, amplitude and latency study; record gastroc-nemius/soleus muscle).
Although the physiatrist did not document an EMG in the patient's chart, the fact that he circled 95860 on the superbill indicates that he may have performed an EMG with the NCS (these studies often go hand-in-hand with one another).
If he confirms that he performed both the EMG and the NCS, he should dictate an addendum to the patient's chart to ensure that his documentation is complete, and you should report 95860 with the NCS codes.
| |
