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©2011 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: "©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided."— Presentation transcript:

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

2 2 Illinois Regulation Training - Medicine Medicine Guidelines Neurology and Neuromuscular Services Electromyography (EMG) Nerve Conduction Studies (NCS) Psychology Ophthalmology Overview 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 3 Illinois Regulation Training - Medicine 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 Lets take a look…

4 4 Illinois Regulation Training - Medicine Medicine Guidelines The fee schedule provides three categories of maximum medical reimbursement for medicine codes : 1) Total component (sometimes referred to as global) 2) Professional component 3) Technical component. Lets continue…

5 5 Illinois Regulation Training - Medicine Medicine Guidelines In addition, when a charge is submitted by one physician who provides both the technical and professional components of a medicine code, designated with no modifier, the maximum medical reimbursement will be the amount listed in the TOTAL column.

6 6 Illinois Regulation Training - Medicine Medicine Guidelines When a charge is submitted for a physicians professional component of a medicine code, as designated with modifier 26, the maximum medical reimbursement will be that listed in the PC AMOUNT column of the fee schedule.

7 7 Illinois Regulation Training - Medicine Medicine Guidelines When a charge is submitted for only the technical component, with the use of modifier TC, the maximum medical reimbursement will be that listed in the TC AMOUNT column. Modifier TC is not found in the CPT book, but it is a modifier for technical component found in the HCPCS Level II. Lets continue…

8 8 Illinois Regulation Training - Medicine Medicine Guidelines The fee schedule recognizes and instructs the use of modifier TC when billing for the technical component of a medicine procedure.

9 9 Illinois Regulation Training - Medicine Medicine Guidelines Medicine services include: Biofeedback Ophthalmology/Optometrists Special Services & Reports Pulmonary Osteopathic Podiatry In fact, the medicine section is extensive and diverse in the types of services it includes.

10 10 Illinois Regulation Training - Medicine 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 Psychology Ophthalmology

11 11 Illinois Regulation Training - Medicine 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.

12 12 Illinois Regulation Training - Medicine Neurology and Neuromuscular Services Two of the most common types of procedures that you will become familiar with are: Lets take a look… Electromyography Nerve Conduction Study

13 13 Illinois Regulation Training - Medicine 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.

14 14 Illinois Regulation Training - Medicine Electromyography Electromyography codes range from CPT to CPT 95874, and are specific to the number of extremities (1-4) and/or different body areas (cranial, larynx, etc). For Example: 95861: Two extremities with or without related paraspinal area 95868: Cranial nerve supplied muscles, bilateral

15 15 Illinois Regulation Training - Medicine Nerve Conduction Studies Lets take a look… Very often, the term electromyography is used synonymously with nerve conduction study. However, they actually refer to two distinct tests.

16 16 Illinois Regulation Training - Medicine 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.

17 17 Illinois Regulation Training - Medicine 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.

18 18 Illinois Regulation Training - Medicine 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

19 19 Illinois Regulation Training - Medicine 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

20 20 Illinois Regulation Training - Medicine 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.

21 21 Illinois Regulation Training - Medicine 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.

22 22 Illinois Regulation Training - Medicine 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…

23 23 Illinois Regulation Training - Medicine 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.

24 24 Illinois Regulation Training - Medicine 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, lets discuss Psychology services... Psychology

25 25 Illinois Regulation Training - Medicine 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.

26 26 Illinois Regulation Training - Medicine 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 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. The drug management code, CPT 90862, is not allowed with these types of psychotherapy codes. Examples: – Individual psychotherapy (20-30 minutes) – Individual psychotherapy (20-30 minutes with medical E/M)

27 27 Illinois Regulation Training - Medicine 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? 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.

28 28 Illinois Regulation Training - Medicine Other Therapeutic Services In addition to Psychology 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.

29 29 Illinois Regulation Training - Medicine 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.

30 30 Illinois Regulation Training - Medicine 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, lets take a look at ophthalmology... Ophthalmology

31 31 Illinois Regulation Training - Medicine 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.

32 32 Illinois Regulation Training - Medicine Correct! An additional E & M charge from CPT would be inappropriate. What does this tell you? Ophthalmology General eye exams include a medical diagnostic evaluation. In this case, an additional E & M charge would be non-reimbursable.

33 33 Illinois Regulation Training - Medicine 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. The service is paid at the lesser of charge or 76% of fee schedule amount. -52 Reduced Services This modifier is used if a service has been reduced from the standard procedure.

34 34 Illinois Regulation Training - Medicine Summary Medicine: Services and Guidelines Electromyography Reimbursement Guidelines Nerve Conduction Study Reimbursement Guidelines Psychology Reimbursement Guidelines Reimbursement of Ophthamological Services


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