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Provided by Coventry Health Care

Texas Medical Bill Reviewer Training

Unit 1: Professional Services

Module 6: Medicine

©2011 Coventry Health Care. All rights reserved.©2011 Coventry Health Care. All rights reserved.Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.

Texas Regulations TrainingAugust 2011

22

Medicine Guidelines Neurology and Neuromuscular

Services Electromyography (EMG) Nerve Conduction Studies (NCS)

Psychology Ophthalmology

Overview



In the State of Texas, there are no specific treatment guidelines in this

area.

However, we should discuss some

general guidelines, types of services in

the medicine section, and

different types of neurology and neuromuscular

services common on workers’ comp bills.


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Medicine Guidelines

Unlike other sections of CPT, the medicine section is comprised of several different types of services, procedures and tests.

The medicine section ranges from 90200-

99199.


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Medicine Guidelines

Medicine services include:

Biofeedback Ophthalmology/

Optometrists Special Services and

Reports Pulmonary Osteopathic Podiatry

In fact, the medicine section is extensive and diverse in the types of services it includes.


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Medicine Guidelines

Some of these services are more common on workers’ compensation bills than others. We will be discussing a subset of those services that include:

Neurology and Neuromuscular

Services

Psychology

Ophthalmology


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Neurology and Neuromuscular Services

Neurology and Neuromuscular services pertain to the diagnosis and treatment of illnesses or injuries that affect the nervous system, the musculoskeletal system, and how they work synergistically.

Neurology and Neuromuscular services include procedures such

as: Sleep studies Electroencephalograms Muscle testing Electromyographies Nerve conduction studies

Do you remember what these two terms mean?

Right! Graphical recordings of the

electrical activity of the brain and

muscles, respectively.


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Neurology and Neuromuscular Services

Two of the most common types of procedures that you will become familiar with are:

Electromyography Nerve Conduction Study


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Electromyography

Electromyography (EMG) tests the electrical potential or electrical activity of muscles.

In other words, electromyography assesses

whether the patient has nerve or muscle damage.

An electromyogramy can be used to diagnose disorders

such as carpal tunnel syndrome.


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Electromyography

Electromyography codes range from CPT 95860 to CPT 95874 and are specific to the number of extremities (1-4) and/or different body areas (cranial, larynx and so forth).

For Example: 95861: Two extremities with or

without related paraspinal area 95868: Cranial nerve supplied

muscles, bilateral


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Nerve Conduction Studies

Very often, the term electromyography is used synonymously

with nerve conduction study.

However, they actually refer to two

distinct tests.


1111


Similar to electromyography, nerve conduction studies evaluate electrical signaling of the motor and sensory nerves in the body.

Nerve conduction studies can be used to

diagnose disorders such as: Peripheral neuropathy

Carpal tunnel syndrome Ulnar neuropathy Guillian-Barré syndrome

In general, nerve conduction studies are

used to evaluate symptoms such as

numbness, tingling, burning or weakness in

the extremities.


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Different components of a nerve conduction study can be billed for testing different types of nerves.

Nerve conduction studies consist of four separate components.

Nerve conduction study components are:

Motor NCS Sensory NCS F-wave study H-reflex study

For example, there are three different nerves

within the upper extremity that can be subject to

motor or sensory testing. Other types of nerves are

only tested with one component of the study.


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The nerves are broken down into four major areas:

Head

Back

Lower Extremity

Upper Extremity

Radial

Ulnar

Median

Tibial

Peroneal

Sural

Femoral

Plantar

Cervical

Thoracic

Lumbar

CoccyxFacial


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Nerve conduction testing may be charged for all

three nerves within the upper extremity.

Each of these nerves can be subject to Motor or

Sensory testing.

Under no circumstance should more than six

nerve conduction studies be allowed per arm.


Upper Extremity

Radial

Ulnar

Median


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Lower Extremity

Tibial

Peroneal

Sural

Femoral

Plantar

Nerve conduction testing may be charged

for: Tibial: Usually only the motor component is tested

Common Peroneal Sural: Sensory component

only Femoral

Occasionally, a test may be performed on both the

medial and lateral plantar branch of the

peroneal nerve.

However, nerve conduction studies can only be billed

per nerve, not per segment of a single nerve.

You will learn later how providers often bill for segments of nerves

incorrectly.


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Head Facial

When facial nerves are tested, only one nerve on

each side of the face should be billed.

Both motor and sensory components can be tested for a total not to exceed

four studies.


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The most commonly performed procedure codes billed for nerve conduction studies are:

Common NCS Procedure Codes:

CPT 95900: Nerve conduction, Motor

CPT 95903: Nerve conduction, Motor with F-Wave

CPT 95904: Nerve conduction, Sensory

CPT 95934: H Reflex Study (Left or Right, up to 2)

Just like other types of services,

providers often bill for nerve conduction

studies incorrectly.

Let’s take a look…


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There are several things to be aware of when you process bills with charges for nerve conduction studies.

Things to Remember: Testing is done per nerve.

However, providers often mistakenly bill per segment.

Why might this be?

Recall that CPT 95903 includes both motor and

F-wave components of

the nerve conduction

study.

Always verify the number of nerves tested. Many providers tend to bill for multiple segments on the same nerve.

CPT 95900 should be denied if providers bill CPT 95903 on the same nerve.


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Psychology




Now that you are familiar with how

some neuromuscular services are

reimbursed, let’s discuss Psychology

services...

Psychology


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Psychology

Psychology focuses on the diagnosis, treatment, and prevention of emotional and behavioral disorders.

Psychology treatments are billed with Psychology treatment codes.

The key Psychology treatment codes for individual psychotherapy are CPT 90804-90829.

CPT 90804 is a BR code because it is “time

unspecified.”This code should always

be denied and sent back to the provider for a specific time period

identification.


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Psychology Treatments

Individual and family Psychology treatment codes may include medical evaluation and drug management services.

If E&M services are billed with a code that includes these services, the E&M Code will be denied.

If E&M services are billed with a code that does NOT include these services, the psych code and the E&M will re-bundle to the appropriate combination code.The drug

management code CPT 90862 is not allowed with these

types of psychotherapy

codes.

Examples:90804 – Individual psychotherapy

(20-30 minutes)90805 – Individual psychotherapy (20-30 minutes with medical E&M)


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Psychology Treatments

In addition to individual psychotherapy codes, there are family psychotherapy codes.

These codes are not specified by time.

Therefore, they are paid once per session.

If multiple units are

billed, what should you do?

That’s right! Check for documentation.

If more than one unit is billed, documentation is

required to verify multiple sessions

occurred on a single date of service.


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Other Therapeutic Services

In addition to Psychology counseling, there are other types of therapeutic services.

Other therapeutic services include:

Electroconvulsive therapy

Narcosynthesis HypnotherapyThese services may be

billed with E & M services if significant, separately identifiable

services are performed.


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Psychology Consultations

Psychology consultations differ from Psychology treatment.

Like other types of consultations, Psychology consultations are only billed with standard E&M consultation codes 99241-99255 and do not involve treatment.

Psychology consultations include:

Examination of the patient. Communication with the

family and primary physician. Preparation of a report.


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Ophthalmology




Now that you have learned how

Psychology services are reimbursed, let’s

take a look at ophthalmology...

Ophthalmology


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Ophthalmology

Ophthalmology is the medical service focused on the diagnosis, treatment and prevention of disorders of the eye.

There has been confusion over whether ophthalmologists can bill for special services if they also charge for a general exam.

CPT Special Ophthalmological

Services are above and beyond the services

included in the general exam and may be billed

separately.


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In this case, an additional E & M charge would be

non-reimbursable.

What does this tell you?

Ophthalmology

General eye exams include a medical diagnostic evaluation.

Specifically, an additional E & M charge from CPT 99201-99285 would be

inappropriate.


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Ophthalmology

Most ophthalmologic procedures are considered bilateral. However, in some instances only a single eye is examined or treated.

Under these circumstances, Modifier 52 is added to the appropriate CPT code.

Modifier 52 Reduced Services

This modifier is used if a service has been reduced from

the standard procedure.


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Summary

Medicine: Services and Guidelines

Electromyography Reimbursement Guidelines

Nerve Conduction Study Reimbursement Guidelines

Psychology Reimbursement Guidelines

Reimbursement of Ophthamological Services

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