Consult with EMG/NCS

tmorgan808

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Hi,
I have a situation where the provider is billing 99242-25, 95912, 95886. He took a history and under it and says he is there for an EMG. Plus additional info about MRI & meds, pain level
EXAM
GA - Alert & oriented, in no acute distress. Mood, affect, and judgment intact.
Vitals
Lungs - breathing unlabored
Heart -regular rate & rhythm
Gait - He has marked antalgic gait with footdrop of the right lower extremity
Neuro - He has a positive SLR. Decreased deep tendon reflex at the right patella. Decreased sensation over the right L4, L5, and even the right S1 dermatome. Motor strength is noted to be very weak with right dorsiflexion, extensor hallucis longus knee extension compared to the left.

Performed EMG/NCS (all valid documentation)

IMPRESSION
Abnormal EMG study
Study shows electrodiagnostic evidence of right L5 lumbar radiculopathy of a moderate degree.

PLAN
recommend increasing gabapentin. Also prescribed Norco.

Is truly a separately identifiable visit? Or should he only be billing for the EMG/NCS.
 
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Does the documentation meet the criteria to qualify as a consultation? If the patient is there for a consult, an E/M has to be done in addition to any testing and so forth.

"What is Required to Support a Consultation?
All three of the CPT E/M key components – history, exam and medical decision making, are required to support the level of service for a consultation. Alternatively, the level of service may be determined on the basis of time, when counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face to face time in the office or other outpatient setting, or floor/unit time in the hospital.) The extent of counseling and/or coordination of care must be documented in the medical record.

The REQUEST – There must be a request for a consultation from an appropriate source and the need for a consultation must be documented in the medical record. The patient may neither be self-referred, nor may the requesting physician simply suggest a physician’s name to the patient. The requesting physician’s name can never be the same as the consulting physician. When the medical record is shared between the referring physician and the consultant, the request is usually found in the requesting physician’s progress note, an order in the medical record, or a specific written request for the consultation. Outpatient documentation may be a specific written request for the consultation from the requesting physician, or the consultant’s record should make a specific reference to the request (this may be included in the dictation.)

The REPORT – the consultant prepares a written report [separate from the encounter notes] of his/her findings, recommendations for treatment, and any therapeutic interventions that have been planned or have begun, and the report is provided to the referring physician."

If any of that is missing from the documentation, then it can't be counted as a consult and therefore couldn't be billed as such.
 
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