Eli's Rehab Report

Published on Sun Sep 04, 2005 PDF

If you have cause, don't be afraid to appeal denials

When another physician sends a patient to your physiatrist for a consultation and possible electromyography (EMG), you may find yourself wondering whether you should report a consultation in addition to an EMG. Clean up this quagmire by finding out just when you should - and shouldn't - put these two codes together.

Won't Always Need an E/M With EMGs

You may find that Medicare carriers' local medical review policies specify that you cannot report an E/M code (like a level-one or level-two consult, 99241-99242) along with an EMG code (95860-95872) unless you have a specific, documented reason to do so.

For instance, CIGNA of North Carolina states that you cannot charge an E/M service "in addition to EMG-NCS codes, unless the referring source has clearly and expressly requested an E/M service."

The reason you may not be able to report a consult code is that a patient may arrive solely for the diagnostic EMG testing at the request of another physician.
 
Example: Your physiatrist sees a patient referred from her primary-care physician (PCP). The PCP requests that the physiatrist perform an EMG to evaluate a patient's unexplained left leg weakness and numbness.
 
In this situation, the PCP isn't asking for a physiatrist's opinion on the treatment of the patient's signs and symptoms or condition. The end goal of this visit is the EMG's diagnostic results.

The physiatrist will therefore provide the testing only and share the results with the PCP. You won't report the consult code (99241, Office consultation for a new or established patient ...) in addition to the testing code (CPT 95860 , Needle electromyography; one extremity with or without related paraspinal areas).

"We occasionally have workers' compensation cases sent to us for EMGs only. In that case, the physician doesn't perform an evaluation and only does the EMG, so we don't charge for an E/M," says Wendy Stuckey, a billing manager at a Coastal Neurology Institute in Mobile, Ala.

You've Got a Chance With an Appeal

You may find an occasion, however, to report an E/M code in addition to the EMG testing. The CIGNA LCD states specifically that you may do so when "the referring source has clearly and expressly requested an E/M service."

Example: A PCP sends his patient to your physiatrist with the complaints of wrist pain and tingling in the hand and fingers. The physiatrist performs an E/M service and provides electrodiagnostic testing (including EMG) to evaluate the patient for carpal tunnel syndrome. In this case you may report an E/M service in addition to the EMG testing. You would append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M code (99241-99242), Stuckey says.

"I've succeeded in reporting a consult with an EMG, but I almost never report it this way," says Neil Busis, MD, director of the neurodiagnostic laboratory at University of Pittsburgh Medical Center in Shadyside. "I complete the consult and then decide if the patient needs an EMG, and if so, what to study. Even so, I report only the EMG - even though technically the referral is a consult in addition to the EMG."

If you do intend to report a consult and an EMG, you may need to fight if your claim is denied. You should write to your insurer's medical director and appeal its policy against paying for E/M services with EMGs.

Good news: If you appeal a decision that denied payment of an E/M service, you'll have a good chance your appeal will succeed - as long as you explain why the E/M was reasonable and necessary as well as separate and significant from the EMG service.

Get Your Documentation Ducks in a Row

To report a consultation, the patient's record must include the written or verbal request for the consult, along with the consultant's opinion and any services ordered or performed. In addition, the consulting physician must communicate his opinion to the requesting physician or other appropriate source in writing.

To make sure you've got all the components of stellar documentation, check the AMA's guidelines in your CPT book and the single specialty exam guidelines from CMS, Busis says.

The relative value units for an EMG don't include an extensive history, physical exam or any medical treatment plan. When you report the EMG alone, you're saying the physiatrist acts solely as a diagnostician. Electrodiagnostic studies cover the actual testing and interpretation of the findings.

Electrodiagnostic studies require a limited history and physical exam to help determine what combination of diagnostic tests the physiatrists should use. In some situations, however, your physiatrist may have to perform a more comprehensive history and examination before determining a final diagnosis as the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) suggests, and you may be able to report an additional E/M service.

Note: For more information, go to the AANEM's position statement at www.aanem.org/practiceissues/positionstatements/EMPositionStatementl.cfm.