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Neurology & Pain Management Coding Alert

EP Studies:

Indications Must Justify Testing

Published on Mon Jul 01, 2002

Payers are strict concerning medical justification for EP studies, but you can get paid if you know how to demonstrate medical necessity. For instance, Blue Cross/Blue Shield North Dakota Local Medical Review Policy # 96.21B specifies EP testing "is covered only when standard methods (i.e., nerve conduction velocities) are not effective for the individual patient." According to the policy, the usual indications for testing are to:

  • Diagnose the presence of lesions in the auditory system external to the brain stem

  • Evaluate brain-stem function in acquired metabolic disorders

  • Measure nerve conduction when not accessible or measurable by standard techniques

  • Document axonal continuity when sensory nerve conduction studies are not obtainable (i.e., nerve injury)

  • Assist in the diagnosis and management of demyeli-nating or degenerative diseases of the brain stem

  • Determine whether sensory symptoms have a nonorganic basis (e.g., conversion reaction)

  • Provide intraoperative monitoring for scoliosis surgery, spinal tumors/malformations and/or aortic aneurysm repair.

    To ensure payment, the medical record should clearly indicate that one or more of the above conditions apply. In addition, some payers specifically deny coverage in some instances. For example, several Medicare carriers don't reimburse for somatosensory EP in the diagnosis or management of ALS (acute lateral sclerosis, 335.24) because SEPs do not pinpoint the diagnosis or change management. Note also that a payer-approved ICD-9 code(s) should accompany the claim. Contact your local carrier for a list of its coverage limitations and acceptable diagnoses.

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