Wiki Non-E/M services being denied by Coventry


Ballwin, MO
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Our office has been having a problem (just this year) with Coventry denying some of our non-E/M services. Here's what's going on:

We do nerve conduction studies in our office. These are not face-to-face, or E/M services, but they are being counted as such according to Coventry because, in the CPT book, the decision tree for New vs Established Patients states, "Received ANY professional service from the physician or another physician in group of the same specialty within the last three years?" It doesn't state, someone at Coventry figured this out and so they have been denying a bunch of our claims this year because sometimes we'll have the patient come in for one of these studies prior to seeing the physician, so we'll code the E/M visit that occurs afterwards as a New Patient visit and they are denying it, stating it should be get the picture. :mad:

So, we tried to argue that the wording in the book was the same as it was last year, but Coventry wouldn't have any of it. Does anyone know of any resource that states anything in print that we could send to them depicting the fact that E/M services have to be face-to-face, etc? We tried to call the AMA but got stuck in a phone loop because we are just billing "civilians." We really need some type of documentation to send with appeals to try and get these paid, because our fear is that since Coventry is trying to pull this BS, who else will follow...Medicare? :confused:

Any help or suggestions anyone can give would be very much appreciated. we have a bunch of denials to appeal...

Thanks in advance,
Can you please give us the exact wording of the denials you've been receiving? Also, I'm assuming you are using CPTs 95900, 95903, 95904, 95905, etc. You state above, "We do nerve conduction studies in our office. These are not face-to-face, or E/M services, but they are being counted as such according to Coventry...." I'm not understanding what you want us to understand. Is the patient present when these studies are being conducted?
The exact wording that we are receiving on the denials is: "Only one initial visit is covered per specialty."

You are pretty much right-on with the cpt codes that you stated, as far as nerve conduction studies...95900, 95903, 95904, 95934, and 95886. And yes, the patient is present when the studies are being conducted, but these are procedures...I was taught that these are not considered face-to-face services, like E/M services. Now, this may be the caveat that won't be defineable...but that's what we are desperately trying to find out.

I need to find some type of documentation in print that defines this, so we can fight these denials...because if Coventry is doing this and are going to take back all this $, who will be next? And why do they get to re-write the rules, to keep money in their own pocketbooks, when our doctors are trying to help their patients get well?

I could go on and on, but I'm just looking for a little help :eek:
That was a good resource, but I'm thinking we need something to clearly define the difference between an E/M visit and a procedure, since Coventry's point of reference (the decision tree in the CPT book, page 5 in the professional edition) has "suddenly" muddled the two into "any professional service."

I'm just at a loss as to where to go for documentation on where to define what each one is...more specifically, an E/M visit...

But thanks for the link. I'm sure we can use that in the future, for other things. :)
Just a couple things that I can point out here...not sure if it helps...
Look at the wording on page 4 of the CPT, under "New and Established Patient" in the revised text. This is where you'll find the "face to face" specification. Not sure why that part wasn't included in the wording for the decision tree, but if you're looking for documentation to include with an appeal, this should help.

Other issue--Here in my clinic, if only an NCV is performed (95900, 95903, 95904, 95934) the physician doesn't actually go into the room with the patient. The techs do the work, then the doctor interprets and writes report. So, like you said, there is no true face to face time between the doctor and patient. However, if an EMG is performed, the doctor does perform that part of the test himself. Might want to check into how this done in your clinic; might lead to more info for you to use in appeals.

Hope this helps some! :)
That's a good point about the nerve conduction tests...I'm going to look at the actual denials and see if they are only denying those, and not the EMG's themselves.
Thanks for pointing that out...


Update: the denials are on EMG's, and those are the ones performed by the!
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This might not be a problem, but make sure that only one physician in your practice is submitting a new vist for the date of service in question. Better to be safe than sorry. :)
Just curious. If the patient has never been seen by the physician, who ordered the study?
Ok, ponder this....a tech is not a qualifying provider to bill for any service. The services in which they would provide are ancilliary to the supervising physician and the one who reads and interprets the services, so in fact, in the payer's eyes, the service is being supervised and priovided by one of your physicians.

If a test is performed and read and interpreted by the physician he has in fact provided a billable service to the patient.

In thinking of your workflow you have to decide if the "juice is worth the squeeze" especially given these denials.

Just another angle to think about.....
This is my question, how does the provider order tests for a patient they have never evaluated?, and if a different provider from another practice ordered this then you staff cannot follow the orders from a different physician. Also standing orders do not apply to patients that have never been evaluated except in emergency situations, so comes back to the question of how then are these tests being performed ahead of any provider evaluation?
CPT states "A new patient is one who has not received any professional services from the physician..." If the service is billed under the physician, then from the payor's view the following appt or the actual face-to-face with the physician would be considered established.

I agree with Debra, why is the physician ordering NCS without first evaluating the patient?