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©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided.

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Presentation on theme: "©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided."— Presentation transcript:

1 ©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Health Care® California Medical Bill Reviewer Re-Certification Unit 2: Official Medical Fee Schedule Module 8: Medicine

2 CA Regulations Training - Medicine March 2010 Medicine Guidelines Neurology and Neuromuscular Services Electromyography (EMG) Nerve Conduction Studies (NCS) Psychiatry Ophthalmology Overview Hi! In this module, you will learn about different types of services in the medicine section of the OMFS. Well 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... Medicine Guidelines Neurology and Neuromuscular Services Electromyography (EMG) Nerve Conduction Studies (NCS)

3 CA Regulations Training - Medicine March 2010 Medicine Guidelines Unlike other sections of the OMFS, the medicine section of the OMFS is comprised of several different types of services, procedures, and tests. In the OMFS, the medicine section ranges from Dialysis Psychiatry Ear, Nose, & Throat Ophthalmology

4 CA Regulations Training - Medicine March 2010 Medicine Guidelines 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 In fact, the medicine section is extensive and diverse in the types of services it includes.

5 CA Regulations Training - Medicine March 2010 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: Neurology and Neuromuscular Services Psychiatry Ophthalmology

6 CA Regulations Training - Medicine March 2010 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 CA Regulations Training - Medicine March 2010 Neurology and Neuromuscular Services Two of the most common types of procedures that you will become familiar with are the: Lets take a look… Electromyography Nerve Conduction Study

8 CA Regulations Training - Medicine March 2010 Electromyography You might recall from your study of medical terminology that an electromyography (EMG) tests the electrical potential, or electrical activity, of muscles. In other words, an electromyography assesses whether the patient has nerve or muscle damage. An electromyography can be used to diagnose disorders such as carpal tunnel syndrome.

9 CA Regulations Training - Medicine March 2010 Electromyography Electromyography codes range from CPT to CPT 95875, and are specific to the number of extremities and/or different body areas. For Example: 95860: One extremity and related paraspinal area 95861: Two extremities and related paraspinal area 95864: Four extremities and related paraspinal area 95868: Cranial nerve supplied muscles, bilateral 95869: Limited study of specific muscles (e.g. thoracic spinal muscles)

10 CA Regulations Training - Medicine March 2010 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.

11 CA Regulations Training - Medicine March 2010 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.

12 CA Regulations Training - Medicine March 2010 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

13 CA Regulations Training - Medicine March 2010 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

14 CA Regulations Training - Medicine March 2010 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.

15 CA Regulations Training - Medicine March 2010 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.

16 CA Regulations Training - Medicine March 2010 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. Lets take a look…

17 CA Regulations Training - Medicine March 2010 Nerve Conduction Studies There are several things to be aware of when you process bills with charges for nerve conduction studies. Things to Remember: The fee schedule states very clearly that 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 a CPT on the same nerve.

18 CA Regulations Training - Medicine March 2010 Psychiatry Psychiatry focuses on the diagnosis, treatment, and prevention of emotional and behavioral disorders. While the psychiatry section of the CPT has been updated, Californias OMFS contains an outdated version of this section. It is important to note providers often bill from the CPT, but will be paid according to OMFS. This makes processing and reviewing bills difficult, as many codes have been added & descriptions have been revised.

19 CA Regulations Training - Medicine March 2010 Psychiatric Consultations Psychiatric consultations differ from psychiatric treatment. Like other types of consultations, psychiatric consultations are only billed with standard E & M consultation codes , and do not involve treatment. Psychiatric consultations include: Examination of the patient. Communication with the family and primary physician. Preparation of a report.

20 CA Regulations Training - Medicine March 2010 Psychiatric Treatments Psychiatric treatments are billed with psychiatric treatment codes. The key psychiatric 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. Psychiatrists are trained early to keep track of the time spent with each patient. Therefore, there is no need to pay a BR code.

21 CA Regulations Training - Medicine March 2010 Psychiatric 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? Thats 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.

22 CA Regulations Training - Medicine March 2010 Psychiatric Treatments Individual and family psychiatric treatment codes also include medical evaluation and drug management services. Therefore, E & M visits and the drug management code, CPT 90862, are not allowed with these types of psychotherapy codes.

23 CA Regulations Training - Medicine March 2010 Other Therapeutic Services In addition to psychiatric counseling, there are other types of 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 CA Regulations Training - Medicine March 2010 Other Therapeutic Services Non-physician providers may bill for their services using medicine codes. Recall from your study of Physicians Services, that non-physician providers include: Marriage counselors Family counselors Child counselors Licensed social workers Lets take a look…

25 CA Regulations Training - Medicine March 2010 Other Therapeutic Services Non-physician providers who bill CPT or CPT should use Modifier – This modifier is used when psychiatric codes are billed by family or marriage counselors, as well as clinical social workers. However, there is no value assigned to this modifier. What does this tell you? This tells you that the modifier is informational only.

26 CA Regulations Training - Medicine March 2010 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. The OMFS specifically states Special Ophthalmological Services are above and beyond the services included in the general exam and may be billed separately.

27 CA Regulations Training - Medicine March 2010 Correct! 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 CA Regulations Training - Medicine March 2010 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. -52 Reduced Services This modifier is used if a service has been reduced from the standard procedure.

29 CA Regulations Training - Medicine March 2010 Summary Medicine: Services and Guidelines Electromyography Reimbursement Guidelines Nerve Conduction Study Reimbursement Guidelines Psychiatry Reimbursement Guidelines Reimbursement of Other Therapeutic Services Reimbursement of Ophthamological Services


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