The Nuts and Bolts of Neurology May 9, 2013 By Marisa Clauson, CPC

Agenda: Anatomy Nerve Conduction Studies (NCS) Electromyelograms (EMGs) Intraoperative Neurophysiology Electroencephalogram (EEG) Cognitive Function

Anatomy Central Nervous System Peripheral Nervous System Brain Spinal Cord Peripheral Nervous System Cranial nerves Spinal nerves Autonomic Nervous System Sympathetic system – uses energy to help the body respond to emergency situations, like “fight or flight” reflex, increase in heart rate and blood pressure. Parasympathetic system – helps the body relax and conserve energy, such as when the body is sleeping.

Central Nervous System Spinal Cord Brain

Peripheral Nervous System * Motor Nerves Allow the brain to stimulate muscle contraction. * Sensory Nerves Nerves that receive sensory stimuli such as how something feels and if it is painful.

Autonomic Nervous System Controls our autonomous involuntary functions such as heart rate, perspiration, pupil dilation and digestion Also controls some voluntary functions such as breathing and swallowing.

Nerve Conduction Studies This study is used to help identify whether a nerve or group of nerves is either diseased or injured. The test is performed by placing two electrodes over the area to be studied, and then the nerves are electrically stimulated.

The velocity of the impulse down the nerve is measured and interpreted by the provider

Coding for Nerve Conduction Studies Codes 95900 – 95904 and 95934 – 95936 have been deleted for 2013 Replaced by seven new codes 95907 1 - 2 Nerve Conduction Studies 95908 3 – 4 Nerve Conduction Studies 95909 5 – 6 Nerve Conduction Studies 95910 7 – 8 Nerve Conduction Studies 95911 9 – 10 Nerve Conduction Studies 95912 11 – 12 Nerve Conduction Studies 95913 13 or more nerve conduction Studies

Nerve Conduction Studies, Continued CPT Guidelines state that Nerve Conduction tests should be limited to the specific nerves and conduction studies needed for the patients specific clinical need. Each type of study is counted only once when multiple sites on the same nerve are stimulated or recorded. See appendix J in your CPT book to see a table of studies which identify the typical number of studies needed for specific conditions. A single NCS includes a sensory nerve conduction, a motor nerve conduction (with or without F-wave is one test), or an H-reflex test. This table represents 90% of cases. This doesn’t mean that the provider can’t do more than indicated in appendix J. However, if he/she does, they may need to appeal for payment.

Electromyelogram (EMG) An EMG study uses a needle to study the electrical activity of muscle fibers. The needle is placed into a muscle and muscle activity is measured as the needle is moved through the muscle in small increments. It is used to assist in determining muscular dysfunction such as neuropathies and problems with nerves supplying the muscles.

EMG’s, continued * CPT codes 95860 - 95887 Codes 95885, 95886, 95887 describe EMG services when NCS (95907-95913) are done jointly on the same day. Use EMG codes 95860-95864 and 95867-95870 when no NCS are performed on the same day.

*+95885: Needle electromyography, each extremity, with related Para spinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (list separately in addition to the code for primary procedure). * +95886: Needle electromyography, each extremity, with related Para spinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (list separately in addition to the code for primary procedure). * +95887: Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study; (list separately in addition to the code for primary procedure).

EMG’s, continued *95870 and 95885 are identified as limited studies. Use these when 4 or fewer muscles are tested in an extremity. *When testing 5 or more muscles in an extremity the use of 95860-95864 or 95886 is appropriate. EXAMPLE: Patient has single lower limb radiculopathy. Motor studies to the peroneal nerve at the ankle, at fibular head, and above fibular head performed. Motor study to the tibial nerve at the ankle and knee performed. Sural sensory at the calf performed. 5 muscle needle exam (e.g. VMO, Glut Medius, Medial Gastroc, Peroneous Longus, and Anterior Tibialis) performed OLD: 94900 x 2, 95904 x1, 95886 NEW: 95908, 95886

EMG’s for Chemodenervation EMG’s are also used to determine the proper site for Botulinum injections in order to denervate an area. There are two add-on codes (95873 – 95874) 95873 is used to report E-stim guidance in addition to chemodenervation codes (64612 – 64614) 95874 is used to report needle EMG for guidance in addition to chemodenervation.

Intraoperative Neurophysiology Neurophysiology is the study of the nervous system function. Typically provided by a technologists who is physically present during the service. Either in the surgical suite or via direct real time connection outside of the surgical room. When the services are provided by the physician or anesthesiologists during a procedure it is included in the procedure and is not separately billable.

Intraoperative Neurophysiology, Continued Code 95920 has been deleted for 2013 Two new codes: 95940 – reported per 15 minute of monitoring in the operating room while providing one-on-one patient monitoring. No other cases may be monitored at the same time. 95941 – reported per 60 minutes of monitoring. Use when there was no physical presence by the monitoring professional in the operating room. Also used when monitoring multiple cases.

Electroencephalography (EEG) Utilizes an electronic recording device to measure and record electrical activity in the brain. Used to evaluate sleep disorders, seizure disorders, brain diseases and head injuries.

Electroencephelography, Continued Routine Electromyelograms (EEG) CPT 95816 – 95822 Includes 20 – 40 minutes of recording Extended Electromyelograms (EEG) CPT 95812 - 95813 Includes reporting time longer than 40 minutes Special EEG Testing (95950 – 95967) CPT 95950 – 95953 and 95956 Used per 24 hours of recording. For recording 12 hours or less use modifier -52 95961 and 95962 use physician time as a basis for unit of service. Use 95961 for the first hour of attendance. Modifier -52 should be used for 30 minutes or less. 95962 for each additional hour.

Cognitive Function Cognitive function testing is coded using CPT 96125 Test are performed face to face with the patient. It is expected that a detailed report of the testing be documented by a qualified provider. Mini-mental health status examinations performed by a provider are included in the Evaluation and Management services. A minimum of 31 minutes must be provided to report any per hour code.