Pennsylvania Medical Bill Reviewer Training

1. Pennsylvania Medical Bill Reviewer Training Unit 1: Professional Services Module 6: Medicine

2. We’ll start by discussing some general guidelines, types of services in the medicine section, and different types of neurology and neuromuscular services common on workers’ comp bills... Overview • Medicine Guidelines • Neurology and Neuromuscular Services • Electromyography (EMG) • Nerve Conduction Studies (NCS) • Psychiatry • Ophthalmology • Medicine Guidelines • Neurology and Neuromuscular Services • Electromyography (EMG) • Nerve Conduction Studies (NCS)

3. Medicine Guidelines • Unlike other sections of CPT, the medicine section is comprised of several different types of services, procedures, and tests. Ophthalmology Dialysis The medicine section ranges from 90200-99199. Ear, Nose, & Throat Psychiatry

4. Medicine Guidelines • In fact, the medicine section is extensive and diverse in the types of services it includes. Medicine services include: • Psychiatry • Dialysis • Ophthalmology • Otorhinolaryngology • Non-invasive Vascular Diagnostic Studies • Pulmonary Services • Allergy & Clinical Immunology • Neurology and Neuromuscular Services • Central Nervous System Assessments/Tests • Chemotherapy Administration • Dermatological Procedures

5. Medicine Guidelines • Some of these services are more common on workers’ compensation bills than others. We will be discussing a subset of those services, which include: Psychiatry Ophthalmology Neurology and Neuromuscular Services

6. 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.

7. Neurology and Neuromuscular Services • Two of the most common types of procedures that you will become familiar with are: Electromyography Nerve Conduction Study Let’s take a look…

8. 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.

9. 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, etc). Electromyography For Example: • 95861: Two extremities with or without related paraspinal area • 95868: Cranial nerve supplied muscles, bilateral

10. Nerve Conduction Studies Very often, the term electromyography is used synonymously with nerve conduction study. However, they actually refer to two distinct tests. Let’s take a look…

11. Similar to electromyography, nerve conduction studies evaluate electrical signaling of the motor and sensory nerves in the body. In general, nerve conduction studies are used to evaluate symptoms such as numbness, tingling, burning, or weakness in the extremities. Nerve Conduction Studies Nerve conduction studies can be used to diagnose disorders such as: • Peripheral neuropathy • Carpal tunnel syndrome • Ulnar neuropathy • Guillian-Barré syndrome

12. 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 Studies Nerve conduction study components are: 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. • Motor NCS • Sensory NCS • F-wave study • H-reflex study

13. The nerves are broken down into four major areas: Nerve Conduction Studies Radial Upper Extremity Ulnar Tibial Median Peroneal Lower Extremity Sural Cervical Femoral Thoracic Back Plantar Lumbar Coccyx Head Facial

14. Radial Upper Extremity Ulnar Median Nerve Conduction Studies 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.

15. Tibial Peroneal Lower Extremity Sural Femoral Plantar Nerve Conduction Studies Nerve conduction testing may be charged for: • Tibial: Usually only the motor component is tested • Common Peroneal • Sural: Sensory component only • Femoral 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. Occasionally, a test may be performed on both the medial and lateral plantar branch of the peroneal nerve.

16. Head Facial Nerve Conduction Studies 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.

17. Nerve Conduction Studies • The most commonly performed procedure codes billed for nerve conduction studies are: Common NCS Procedure Codes: Just like other types of services, providers often bill for nerve conduction studies incorrectly. • 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) Let’s take a look…

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

19. Psychiatry Now that you are familiar with how some neuromuscular services are reimbursed, let’s discuss psychiatry services... • Medicine Guidelines • Neurology and Neuromuscular Services • Electromyography (EMG) • Nerve Conduction Studies (NCS) • Psychiatry • Ophthalmology • Psychiatry

20. Psychiatry focuses on the diagnosis, treatment, and prevention of emotional and behavioral disorders. Psychiatric treatments are billed with psychiatric treatment codes. Psychiatry • The key psychiatric 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.

21. Individual and family psychiatric treatment codes may include medical evaluation and drug management services. If E/M services are billed with a code which includes these services, the E/M Code with be denied. If E/M services are billed with a code which does NOT include these services, the psych code and the E/M will re-bundle to the appropriate combination code. Psychiatric Treatments 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)

22. In addition to individual psychotherapy codes, there are family psychotherapy codes. Psychiatric Treatments These codes are not specified by time. Therefore, they are paid once per session. That’s right! Check for documentation. If multiple units are billed, what should you do? If more than one unit is billed, documentation is required to verify multiple sessions occurred on a single date of service.

23. In addition to psychiatric counseling, there are other types of therapeutic services. Other Therapeutic Services Other therapeutic services, which include: • Electroconvulsive therapy • Narcosynthesis • Hypnotherapy ...may be billed with E/ M services if significant, separately identifiable services are performed.

24. Psychiatric consultations differ from psychiatric treatment. Psychiatric Consultations • Like other types of consultations, psychiatric consultations are only billed with standard E/M consultation codes 99241-99255, and do not involve treatment. Psychiatric consultations include: • Examination of the patient. • Communication with the family and primary physician. • Preparation of a report.

25. Now that you have learned how psychiatry services are reimbursed, let’s take a look at ophthalmology... Ophthalmology • Medicine Guidelines • Neurology and Neuromuscular Services • Electromyography(EMG) • Nerve Conduction Studies (NCS) • Psychiatry • Ophthalmology • Ophthalmology

26. 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. Ophthalmology

27. Ophthalmology • General eye exams include a medical diagnostic evaluation. What does this tell you? Correct! In this case, an additional E & M charge would be non-reimbursable. Specifically,an additional E & M charge from CPT 99201-99285 would be inappropriate.

28. 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. Ophthalmology 52 Reduced Services This modifier is used if a service has been reduced from the standard procedure.

29. Psychiatry Reimbursement Guidelines Medicine: Services and Guidelines Electromyography Reimbursement Guidelines Reimbursement of Ophthamological Services Nerve Conduction Study Reimbursement Guidelines Summary