Neurology & Pain Management Coding Alert

When you assign codes describing electrodiagnostic testing (such as NCS and EMG), you must be careful not to exceed the payer's guidelines. To standardize these guidelines, the American Association of Electrodiagnostic Medicine (AAEM) has developed a chart listing the "maximum number of tests necessary in 90 percent of cases," to which many insurers look when designing medical review policies.

Note, for instance, that the AAEM chart recommends a maximum of six units of mixed nerve NCS (95903) for investigation of bilateral CTS.
 
"You can't test and bill indiscriminately," says Tiffany Schmidt, JD, the AAEM's policy director. "Overutilization and overbilling harms the patient and adversely affects reimbursement for all physicians."
 
In a minority of cases (10 percent or fewer), the AAEM's recommended maximum number of tests for a given diagnosis may not provide sufficient information to properly evaluate the patient's condition. "In very complex cases, the maximum numbers in the table will be insufficient for the physician to arrive at a complete diagnosis," Schmidt says. "Also, in cases where there are borderline findings, additional tests may be required to determine if the findings are significant.
 
"For example," Schmidt says, "when a patient arrives with a provisional diagnosis of CTS on the right side, the neurologist may have to perform electrodiagnostic studies on the patient's left side for comparison purposes."
 If payers balk at reimbursing for necessary procedures that exceed the AAEM recommendations, remind them that diagnostic judgments based on inadequate information lower the quality of patient care and increase the risk of patient injury due to incorrect diagnosis, misdiagnosis or improper treatment.