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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.

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Presentation on theme: "Provided by Coventry Health Care Texas Medical Bill Reviewer Training Unit 1: Professional Services Module 6: Medicine ©2011 Coventry Health Care. All."— Presentation transcript:

1 Provided by Coventry Health Care Texas Medical Bill Reviewer Training Unit 1: Professional Services Module 6: Medicine ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.

2 Texas Regulations Training August   Medicine Guidelines   Neurology and Neuromuscular Services   Electromyography (EMG)   Nerve Conduction Studies (NCS)   Psychology   Ophthalmology Overview   Medicine Guidelines   Neurology and Neuromuscular Services   Electromyography (EMG)   Nerve Conduction Studies (NCS) 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.

3 Texas Regulations Training August 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

4 Texas Regulations Training August 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.

5 Texas Regulations Training August 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

6 Texas Regulations Training August 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 Texas Regulations Training August Neurology and Neuromuscular Services Two of the most common types of procedures that you will become familiar with are: Electromyography Nerve Conduction Study

8 Texas Regulations Training August 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 Texas Regulations Training August Electromyography Electromyography codes range from CPT to CPT 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

10 Texas Regulations Training August Nerve Conduction Studies Very often, the term electromyography is used synonymously with nerve conduction study. However, they actually refer to two distinct tests.

11 Texas Regulations Training August Nerve Conduction Studies 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.

12 Texas Regulations Training August Nerve Conduction Studies 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.

13 Texas Regulations Training August Nerve Conduction Studies 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 Coccyx Facial

14 Texas Regulations Training August 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. Nerve Conduction Studies Upper Extremity Radial Ulnar Median

15 Texas Regulations Training August Nerve Conduction Studies 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.

16 Texas Regulations Training August Nerve Conduction Studies 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.

17 Texas Regulations Training August Nerve Conduction Studies 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…

18 Texas Regulations Training August Nerve Conduction Studies 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 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 should be denied if providers bill CPT on the same nerve.

19 Texas Regulations Training August Psychology Medicine Guidelines Neurology and Neuromuscular Services Electromyography (EMG) Nerve Conduction Studies (NCS)   Psychology   Ophthalmology Now that you are familiar with how some neuromuscular services are reimbursed, let’s discuss Psychology services...   Psychology

20 Texas Regulations Training August 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 CPT 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 Texas Regulations Training August 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 is not allowed with these types of psychotherapy codes. Examples: – Individual psychotherapy (20-30 minutes) – Individual psychotherapy (20-30 minutes with medical E&M)

22 Texas Regulations Training August 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.

23 Texas Regulations Training August Other Therapeutic Services In addition to Psychology counseling, there are other types of therapeutic services. Other therapeutic services include:   Electroconvulsive therapy   Narcosynthesis   Hypnotherapy These services may be billed with E & M services if significant, separately identifiable services are performed.

24 Texas Regulations Training August Psychology Consultations Psychology consultations differ from Psychology treatment. Like other types of consultations, Psychology consultations are only billed with standard E&M consultation codes and do not involve treatment. Psychology consultations include:   Examination of the patient.   Communication with the family and primary physician.   Preparation of a report.

25 Texas Regulations Training August Ophthalmology Medicine Guidelines Neurology and Neuromuscular Services Electromyography (EMG) Nerve Conduction Studies (NCS) Psychology   Ophthalmology Now that you have learned how Psychology services are reimbursed, let’s take a look at ophthalmology...   Ophthalmology

26 Texas Regulations Training August 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.

27 Texas Regulations Training August 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 would be inappropriate.

28 Texas Regulations Training August 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.

29 Texas Regulations Training August Summary Medicine: Services and Guidelines Electromyography Reimbursement Guidelines Nerve Conduction Study Reimbursement Guidelines Psychology Reimbursement Guidelines Reimbursement of Ophthamological Services


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