Wiki All EMGs with NCS for bilateral extremities billing question

[carlystur]

Our new Pain Management provider has just yesterday informed me that he and his staff have always been billing them like this:

"Bilateral Upper Extremities:
95911 for 9-10 studies
95886
95886, 76 modifier

Bilateral Lower Extremities:
95910 for 7-8 studies
95886
95886, 76 modifiers

The lower extremity NCS is one less than the upper extremities. I typically, do needle exam on at least 5 muscles for each extremity to qualify for the 95886 code. It needs to be entered twice for charges, otherwise we are only collecting for half the work."

As I understand this process for him, the repeated procedure would be done the next day because the procedure was not finished on the original date of service for various reasons. The issue I'm having is our coding book says those get coded per extremity in units with no modifier seemingly necessary. He wants ALL of his EMGs with Nerve Conduction Studies to be billed this way because they've done it that way for the past 5-6 years stating that their coder at the time told them that "because it is a procedure and not something that can be measured such as 2 bottles of medications or 2 units (mL) of depo-medrol 40mg/mL that I should be using a 76 modifier. He said that this indicates that we repeated the same procedure twice in the one visit." Another of our current coders (besides me) told me that it would get billed that way when the procedure wasn't finished for some reason, which I get. But they want ALL of the ones he does coded that way.

Am I missing something here?

EDIT: This also reeks to me of wanting to get paid more regardless of whether or not it was medically necessary considering he wrote: "I typically, do needle exam on at least 5 muscles for each extremity to qualify for the 95886 code."

 

[jkyles]

Hi there, I'm a little confused about the scenario, but if this is just for instances when a patient had to come back because they couldn't complete the service for some reason it would be the NCS code and the EMG code x Units of Service. Medicare allows up to 4 per day so I'm not sure why the modifier is necessary.

I agree that the statement that indicates the doctor is performing a service to qualify for a code warrants a closer look. However, if the medical necessity of the service is in the note, you'll be fine in the event of a chart review. Another problem would be if splitting the service into two visits is routine, because that could look like an attempt to get around the limit on NCS services. There was an audit on electrodiagnostic tests performed during 2011, which was shortly before the codes were revised to rein in utilization. It's not unlikely that MACs/the OIG are still keeping an eye on claims. https://oig.hhs.gov/oei/reports/oei-04-12-00420.pdf

 

[carlystur]

Hi there, I'm a little confused about the scenario, but if this is just for instances when a patient had to come back because they couldn't complete the service for some reason it would be the NCS code and the EMG code x Units of Service. Medicare allows up to 4 per day so I'm not sure why the modifier is necessary.

I agree that the statement that indicates the doctor is performing a service to qualify for a code warrants a closer look. However, if the medical necessity of the service is in the note, you'll be fine in the event of a chart review. Another problem would be if splitting the service into two visits is routine, because that could look like an attempt to get around the limit on NCS services. There was an audit on electrodiagnostic tests performed during 2011, which was shortly before the codes were revised to rein in utilization. It's not unlikely that MACs/the OIG are still keeping an eye on claims. https://oig.hhs.gov/oei/reports/oei-04-12-00420.pdf

The procedure doesn't seem to have been split into multiple visits with each patient since they are attached to the same encounter, which is what I work with after the doctors are done choosing their CPT/ICD-10 codes and before they lock their encounters so claims can be created. I was told later in the day yesterday that if a modifier were needed, it would be 59 or the equivalent X_ modifier. Thank you for sharing all of this. I knew it didn't look right, especially when I saw how it should be billed out in my CPT book by units (by extremity, in other words). Thankfully, we just hired another coder who agreed that the doctor and his clinical staff (as well as our other established coder) were incorrect regarding this issue and that I was right. I've notified our Revenue Cycle Manager about this issue and, I believe, we're going to have a meeting about it later today. The last thing I saw with the EMG claims, the Clearinghouse had accepted it.

Side note: I was just made aware yesterday that we can have coding rules in our software so it won't allow these types of mistakes, but we mostly don't. Our RCM said she would look into getting that done so I guess we'll see. Also, hopefully I can get access to the company Codify so that I do not have issues like this again.