Neurology & Pain Management Coding Alert

Shore up your diagnostic testing claims, medical necessity in 2004 You've assigned the right code to an electro-myography (EMG) or other diagnostic test, confirmed that the neurologist's interpretation is in the file, and clipped the ordering physician's EMG order to the patient's chart. Another pristine chart guaranteed to bring your practice quick payment, right? Maybe not: If a physician who is excluded from the Medicare program ordered the diagnostic test in the first place, Medicare and other federal payers won't reimburse you for your work.
 
Specifically, the U.S. Office of Inspector General's (OIG's) 2004 Work Plan states, "Under Federal regulations, physicians who are excluded from federal healthcare programs are precluded from ordering, as well as performing, services for Medicare beneficiaries. During a current review, we identified a significant number of services that had been ordered by excluded physicians."
 
Neurology practices simply can't afford to have scores of diagnostic testing services denied just because an ordering physician was excluded from the Medicare program - and this is particularly frustrating when physicians don't self-disclose that they are excluded.
 
So how can you credential your facility's ordering physicians? The OIG maintains a database of excluded physicians. You can either download the entire database or search it using physician or business names. To access the database, visit http://oig.hhs.gov/fraud/exclusions.html. Documenting Medical Necessity Is Necessary In 2004, you'll need to work even harder than before  to verify medical necessity for all services and tests, particularly nerve conduction studies, because the OIG will be looking carefully at medical necessity. Indeed, the plan states, "We will assess the medical necessity of diagnostic tests, such as nerve conduction studies, performed by physicians ... Medicare-allowed amounts for nerve conduction studies increased from $136 million in 2000 to $186 million in 2001 - approximately 37 percent." The OIG also plans to focus on medical necessity for E/M services.
 
Generally, demonstrating medical necessity is a function of complete and accurate ICD-9 coding, such as providing all relevant primary and secondary diagnoses, reporting sign and symptoms codes to justify testing, using E codes and late effects to describe causes, and linking diagnoses directly to their corresponding procedure codes. "The information in the physician's documentation should substantiate any diagnosis he or she selects when ordering diagnostic tests," says Bruce H. Cohen, MD, co-director of the Brain Tumor Center at the Cleveland Clinic Foundation in Cleveland.
 
For example, a diabetic patient with suspected neuropathy visits the neurologist for diagnostic testing. During the exam, the patient reveals signs and symptoms (such as 787.02, Nausea; 787.01, ... with vomiting; 787.03, Vomiting; 789.06, Abdominal pain, epigastric, etc.) that suggest gastroparesis (536.3), a neuropathy-related gastrointestinal disorder. For a diabetic, gastroparesis is especially serious. Oral medications may never reach the bloodstream. Insulin injections [...]