Neurology & Pain Management Coding Alert

Raw data that proves medical necessity sustains your claims

If your neurologist didn't find a new diagnosis during an electromyography (EMG) test, Medicare may view the EMG (95860-95872) as "preventive" rather than "diagnostic." But there's still hope - and most of it comes in the form of documentation.

Coding example: A primary-care physician refers a patient with extremity numbness (782.0) to your practice, and the neurologist finds evidence of carpal tunnel syndrome (354.0) during an EMG.

In this case, you should use 354.0 on your claim. If the neurologist is not able to make a diagnosis following the EMG, however, you can revert back to the pre-EMG documented signs and/or symptoms. You should always check to see if the patient's carrier lists his pretesting signs and/or symptoms as covered diagnoses.

Tactic 1: One overriding tactic is making sure you submit sufficient documentation. Interpreting EMG results can be complex because physicians interpret sounds and waveforms produced by EMG needles real-time. Therefore, you may earn your reimbursement by providing raw data for 1. the exact location of the EMG needle electrode insertion sites in the patient's body, 2. the auditory output of the EMG during the exam, and 3. the correlation between the recorded waveforms and the patient's effort during voluntary muscular contraction.

Tactic 2: Check your Medicare carrier's policy bulletin regarding EMGs before your neurologist performs the test to determine coverage limitations and covered diagnoses. Get a letter of medical necessity or office notes from the referring physician prior to the test and have the patient sign an advance beneficiary notice prior to the test if you see that the carrier doesn't cover pretesting sign/symptom(s).

Tactic 3: If the payer denies your patient's pre-EMG diagnosis, you can send a paper claim with a copy of the carrier's covered diagnoses with your patient's diagnosis highlighted, a cover letter explaining why the physician performed the EMG, and copies of the chart notes.

Tactic 4: Your physician may perform an EMG on a patient more than once for reasons such as 1. second diagnosis, 2. inconclusive diagnosis, 3. rapidly evolving disease, 4. course of the disease, 5. unexpected course or change in the course of the disease, and 6. recovery from injury. Take special care in determining how many occurrences per calendar year your carrier will reimburse. Don't 'Overtest' Insurers won't pay for an unlimited number of tests, and they set testing limits for individual conditions.

"Reasonable limits can be set for the frequency of repeat EMG testing per year for a given patient by the same physician," says Tiffany Schmidt, JD, director of policy at AAEM.

For instance, carriers may reimburse two tests for carpal tunnel and radiculopathy, among others, and three tests for motor neuropathy and plexopathy

"These limits do [...]