Neurology & Pain Management Coding Alert

Rapidly developing diseases may give cause for more frequent tests

When reporting electrodiagnostic (EDX) tests, you have to worry about more than how many test units you bill. You also have to worry about how often you bill a given test for any one patient.

For example: Here's a typical payer local coverage determination for nerve conduction studies (95900-95904): "Utilization of nerve conduction studies ... at a frequency of two sessions per year would be considered appropriate for most conditions (e.g., unilateral or bilateral carpal tunnel syndrome, radiculopathy, mononeuropathy, polyneuropathy, myopathy and neuromuscular junction disorders). Nerve conduction velocity studies performed more frequently than twice a year should be reviewed for medical necessity."

Payers stipulate similar restrictions for most types of EDX testing, including electromyography, H-reflex studies and others.

Document Reasons for Additional Tests There are clinical situations in which a patient may require repeat testing. You should include such conditions in your documentation, says Tiffany Schmidt, JD, policy director for the AANEM. Examples include:
  the development of a new condition (that is, a diagnosis is made on the first visit, but the patient subsequently develops a new set of symptoms)
  an inconclusive diagnosis - such as when a serious diagnosis is suspected but the results of the needle EMG/NCS examination are insufficient
  when the patient has a rapidly developing disease (for example, Guillain-Barr syndrome)
  if the course of a disease changes unexpectedly
  if a patient is recovering from an injury (for example, traumatic nerve injury) and requires repeat evaluations to monitor recovery, to help establish prognosis and/or to determine the need for and timing of surgical intervention. If the physician determines that a patient's condition requires EDX testing in excess of a payer's frequency guidelines - and he can document medical necessity - the payer should recognize the claim.

In such situations, the AAEM recommends that you include the reason for the repeat study in the body of the report or in the patient's chart and have the physician document a comparison with the previous test results.