Neurology & Pain Management Coding Alert

Neurologists reporting H-reflex studies should append modifier -50 (bilateral procedure) to the appropriate code to indicate to the carrier that bilateral testing is necessary. In addition, carriers often specify, and strictly enforce, a limited number of diagnoses to support these tests. Failure to append the modifier, or use of improper ICD-9 codes, will result in claim delays and denials.
Bilateral Testing Establishes a Baseline
H-reflex testing measures and records amplitude and latency of muscles and may be used to diagnose nerve damage or disease (e.g., spinal stenosis or radiculopathy), says Tiffany Z. Eggers, JD, MPA, policy director/ legislative counsel for the American Association of Electrodiagnostic Medicine (AAEM) in Rochester, Minn. These tests can provide useful complementary information to evaluate a suspected radiculopathy and provide additional electrodiagnostic information to support a diagnosis although in some cases they may be the only abnormal study performed. CPT specifies two codes to report these procedures, depending on the muscle(s) tested:
  
95934 H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle
  
95936 ... record muscle other than gastrocnemius/soleus muscle.
Code 95934 should be used when the muscles of the lower leg (i.e., the calf muscle) are tested. Code 95936 applies to any other tested muscles, e.g., the flexor carpi radialis, in the arm. The intrinsic small muscles of the hand and foot may sometimes, although rarely, be tested and should also be reported with 95936, Eggers says.
 
When performing an H-reflex study, the neurologist looks for an abnormal muscle response. To establish a "baseline" measurement, he or she will perform the test on each side of the patient's body and compare the response of the "unaffected" to the "affected" muscle. According to information available on the AAEM Web site, "H-reflex studies usually must be performed bilaterally because symmetry response is an important criterion for abnormality."
 
Note: The AAEM Web site (www.aaem.net) contains a "Recommended Policy for Electrodiagnostic Medicine" that provides additional information on H-reflex studies and other electrodiagnostic tests.
 
Laureen Jandreop, OTR, CPC, CCS-P, CPC-H, consultant-owner and trainer for A+ Medical Management and Education in Egg Harbor City, N.J., offers the example of a patient who complains of shooting pain and/or numbness in the right leg. The neurologist tests the patient via an H-reflex study. He or she first tests the left calf muscle to find the normal response for that patient, then checks for variation by testing the right calf. A delayed or nonexistent response on the affected side of the body may indicate nerve damage.
 
CPT descriptors for 95934 and 95936 specify "muscle" rather than "muscles" and as such AAEM and Medicare consider these to be unilateral codes. Therefore, when the tests are performed on both sides of the body, the appropriate [...]