Part B Insider (Multispecialty) Coding Alert

Published on Fri Mar 06, 2009 PDF

Tip: Counting minutes may not aid reimbursement.

Question: Our physician performed EMGs in a hospital setting on four different patients. Three of them had Medicare and one had Wisconsin Medical Assistance. I billed them as an EMG and each insurer denied the charge because the insurer doesnt pay for EMGs at that place of service (hospital). How do I get paid for the extra time spent with these patients and for the EMG?

Answer: You should report the corresponding CPT code with modifier 26 (Professional component) appended, which indicates you are billing only for the professional component. The insurer should process this portion of the diagnostic study without difficulty as long as the service meets any medical necessity or other payer coverage requirements.

Technical portion: As for the technical portion of these diagnostic studies, if your physician indeed provides not only the computer and supplies but also performs the tests -- that is, provides all the technical component of the study -- the physician needs to look to the facility for reimbursement for this portion of the services. It is best if this can be discussed and reimbursement agreed upon prior to the diagnostic studies being performed.

Medicare processes reimbursement for facilities based on the patients diagnoses during the hospital stay, called Diagnosis Related Groupers (DRG). In that method, the facility receives payment that includes allowances for the technical component of all diagnostic studies.This includes even the technical component of EMG and nerve conduction studies that are performed by an independent physician with his own equipment. Medicare will not and cannot allow separate payment to the physician for the technical component as they are already including the allowance for the technical portion of any diagnostic study in the facilities payment.

Is time a component? Time would only be a factor if your physician was also providing an E/M service in which either the majority of the time was spent in counseling and/or coordination of care or prolonged E/M service.

The time spent performing the diagnostic studies is not included in the total time calculation.