Neurology & Pain Management Coding Alert

Be wary of overlaps between services and descriptors.

Coding can get tricky when physicians perform multiple services during the same patient encounter, especially when you delve into autonomic function tests with EMGs.

Case in point: A Neurology and Pain Management Coding Alert subscriber wrote that her neurologist performed multiple autonomic function tests and EMGs during the same encounter. Notes indicated that he performed one complete needle EMG study on one limb and a limited needle EMG on the contralateral extremity.  On the charge ticket, the physician marked 93660, 95921, 95922, and 95923 for the autonomic tests and 95885/95886 for the EMG.

Read on for the best way to tackle this case, along with the rationale for each code you can report from Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

Step 1: Pick Apart the Suggested Codes

You can often report autonomic function tests on the same day (and during the same encounter) as EMGs, but it’s not a given. Start by examining each code the neurologist suggested:

• 93660 – Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention)
• 95921 – Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio
• 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 5 minutes of passive tilt
• 95923 – Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential
• +95885 – Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)
• +95886 – Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).

Step 2: Look for More Accurate Options

Physicians and other providers might know which codes apply to many of their most common scenarios, but they don’t always know the latest ins and outs of coding. Your responsibility as a coder is to know when revised or new codes might be a more accurate choice than familiar stand-by options.

Example: A new code was created in 2013 that appears to be the combination of 95921 and 95922: code 95924 (Testing of autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt). If the physician performed all the requirements identified for both studies, as identified in the Autonomic Function Test section guidelines, then you should report 1 unit of the 95924 code instead of 95921 with 95922. 

Step 3: Check for Bundles and Coding Notes

You should always pay attention to coding guidelines and check whether codes are bundled, especially with the number of codes the neurologist in the example is suggesting. Here’s what you’ll find when you look at CPT^® notes and dig into Correct Coding Initiative (CCI) edits:

• Codes 95921, 95922, and 95924 are each Column 2 codes for 93660, according to CCI edits. If the physician performs separate testing on the patient’s parasympathetic and sympathetic adrenergic autonomic nervous function as well as on the patient’s cardiovascular function, then the CCI edits allow use of a modifier (such as 59, Distinct procedural service) to bypass the bundling edit with 95924. The same is true if you have supporting documentation to justify reporting either 95921 or 95922 with 93660. Append the modifier to the Column 2 code.
• CPT^® coding instructions state that you cannot bill 95921 and 95922 together. Notes with new code 95924 instruct that you cannot report 95924 in conjunction with 95921 or 95922. Choose the single code that best represents the physician’s service.
• Code 95923 for sudomotor autonomic nervous system function is not bundled by CCI edits into either 93660 or 95924. However, the testing must meet the criteria for the code description in order to bill it.
• Because +95885 and +95886 are add-on codes, you always list the associated primary procedure code first on your claim. Some nerve conduction studies can serve as primary codes for EMG add-ons +95885 and +95886, but the physician in the example did not complete a nerve conduction study during this encounter. Therefore, you cannot submit codes +95885 or +95886 for the EMG on this claim. You can, however, report stand-alone EMG code 95860 (Needle electromyography; 1 extremity with or without related paraspinal areas) because the neurologist documented that he also completed separate EMG testing.
• If you were able to report the add-on EMG codes, note that CCI edits bundle +95885 into +95886. This is because code +95885 represents a limited extremity EMG study, while +95886 is for a complete extremity EMG study. It would only be appropriate to report +95885 and +95886 on the same claim if the limited study was performed on a different limb from the complete extremity study. You would append a modifier to bypass the bundling edit.

Case Example Solution: Here’s What to Report

If you were coding the example case, your final claim would include:

• 93660 for cardiovascular function evaluation
• 95924 for testing autonomic nervous system function (if you have documentation that shows the tests are separate from the cardiovascular evaluation; append a modifier to break the edit bundle)
• 95923 if the physician meets the testing criteria
• EMG testing code(s) 95860 and others if appropriate.