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Why Americans Should be Outraged at the Healthcare System

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Dr. Robert Pearl, the former CEO of The Permanente Medical Group, the nation’s largest medical group, is one of today’s foremost thought leaders and authors in the healthcare industry. He shares his personal stories peppered with current, relevant statistics that paint an accurate picture of the United State’s healthcare system  and dispel any illusions or misinformation.  He recently spoke at MediRevv’s annual RevvCycle Summit and shared some engaging information. 

For instance…

It turns out that there is a much cheaper and less invasive option for colonoscopies that produce the same results—but your doctor might not to tell you that. The reason why? Money, of course, as Dr. Pearl, tells us in his best-selling book Mistreated: Why We Think We’re Getting Good Health Care—And Why We’re Usually Wrong.

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Reconciling Value-based Payments in a Fee-for-service Environment

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Reconciling Value-based Payments in a Fee-for-service Environment

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All hospitals — regardless of size — are struggling to realize the change to value-based care. Most are stuck on the platform, with only 10% of hospitals having a majority of their payer contracts reflecting value-based reimbursement models, like shared savings, bundled payments or capitation.

Increases in U.S. healthcare spending continues to outpace other developed countries. The value-based payment models attempt to improve efficiency and tie the quality of care to payment. Even with the reluctance to jump on the train, there have been some significant advances in 2018:

  • UnitedHealthcare’s bundled payment program for joint replacement has cut readmission rates by 22%.
  • Pennsylvania’s Medicaid program began value-based reimbursements covering all 67 counties for their managed behavioral health organizations (MHBOs).

So, how do industry leaders accelerate the drive toward value-based care?

46% of health care leaders expect value-based reimbursements to increase the margin of profitability, according to a 2018 poll by KPMG. With the strategic innovations that are required to make what is expected a reality, it’s clear that healthcare leaders must master new skill sets.

But there’s also a bigger picture to consider, which spans all departments, while still balancing financial responsibilities.

 

Optimize Margins as Revenue Drops

There is an increase of pressure on hospitals to reduce inpatient volumes and readmission. Proposed hospital reimbursement changes included in CMS’ Outpatient Prospective Payment System rule for 2019 would likely further ding hospital margins, according to a Moody’s Investors Service report.

Meeting value-based goals requires hospitals to reduce utilization among their populations, therefore reducing their procedure volume and revenue in the short run. To minimize the financial strain, leaders are focusing on readiness—and that includes payers, providers and patients.

Having no set time frame for how long the transition will take is an uncertainty that plagues many organizations, but here are some ways to start preparing if you’re not already in the thick of it.

 

  • Relationships with payers need to be strong and built on trust by delivering results on your current fee-for-service contracts. This ensures positive development and cooperation when the time comes for risk-based contracting.

 

  • Focus on technology implementation; it’s essential to gather the most relevant information and analyze/adapt medical services so the proper outcomes can be achieved. This is the only way the complexities of value-based care can take off and be sustainable organization-wide.

 

  • Revenue cycle management is most critical — you must work to improve efficiency to demonstrate your organization’s ability to successfully execute value-dependent payments. It’s like introducing a new variable to a formula and you have to balance the equation.

Understand the Relationship Between Patient Experience and Financial Results

Value-based reimbursement impacts your providers, payers, and patients, but don’t forget about the fourth “P” word — your people.

Creating the right culture and cultivating your talent is what will set your organization apart. Assess your staff for the right skills needed for value-based reimbursement which include:  

 

  • A focus on patient experience
  • Motivation to achieve outcomes
  • Technology skills to use and analyze data effectively

Ensure you are attracting the best talent to stay competitive in your market. If you lack the internal resources to accomplish this or your market simply does not produce this talent, an outside revenue cycle management firm may help in developing your employee’s skill sets in the above areas.

Understanding the relationship between patient experience and financial results is essential at every level of the organization. Educating front-line staff will help create value for patients and payers alike. Keeping perspective on the strategic execution of the value-based initiatives keep all staff focused on the high-level priorities and goals that are outlined in the plan.

For revenue cycle leaders project planning is useless unless it is grounded in implementation details—this includes where to obtain the needed resources and how they will be managed.

Portrait of a female doctor holding her patient chart on digital tablet in bright modern hospital

Track Quality Measures Through Analytics

CMS has standardized quality measurements for the hospital, home health and other care settings, and because Medicare makes up around 30% of most provider’s net revenue it’s dually important to adhere to reporting those quality measures accurately.

That’s not all payers and providers have to look at when it comes to effectively measuring quality and outcomes. Where it gets complicated is that almost every individual payer has a unique set of measurements required from providers, and the specifics across payers do not align well. This results in hospitals adapting their technology to be able to home in on what each payer wants to be measured and extract that data.

Each payer has goals and priorities about what quality healthcare means for their members, and because this is all relatively new the attempt to standardize measurements among payers hasn’t really been coordinated aside from a few exceptions.

On top of this, providers have another set of measurements and quality drivers that are used internally to prioritize their strategic focus. The reason for all of these efforts is to lower costs and improve care for patients, but between regulatory reporting, payers and providers it ends up being a complex and time-consuming situation.

The takeaway for healthcare leaders who want to begin simplifying this reporting process means:

  • Creating a solid definition of what quality is and then deciding what factors and data need to be used to measure it.
  • Current systems are often good at collecting lots of data, but more time should be spent distributing it and analyzing it internally among departments.
  • Invest in an analytics infrastructure to overcome these challenges

The Bottom Line

In the evolution of the healthcare industry, we have come to a crossroads—some hospitals will not be able to step off of the proverbial platform and move progressively forward on the train to fully establish value-based care—like effectively manage shared savings programs—and those organizations will ultimately be left behind.

For leaders who are trying to get aboard the train, considering the above steps will bring you closer the major goals like:

  • Managing shared savings programs
  • Reducing readmission rates
  • Understanding population health
  • Improving quality measures through analytics
  • Lowering operating costs

This will be an ongoing, difficult process, but it’s worth it to efficiently deliver outstanding care to your patients.

Learn more about How 3M is using AI to reduce tech burdens in the revenue cycle process

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Tips For Best Practice to Improve Back-end Revenue Cycle Functions

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“Good things take time, as they should. We shouldn’t expect good things to happen overnight. Actually getting something too easily or too soon can cheapen the outcome.” — John Wooden

The above quote can be applied to almost every endeavor, but as it applies to the back office functions of a business office— it’s important to take the time to make lasting improvement—not just put a band-aid on for a quick fix. The time-consuming work includes setting goals for performance improvement initiatives, education of staff, regular meetings, performance discussions, and attention to detail on all aspects of the revenue cycle.

Partnering with an outsourcing firm that has expertise in best practices for back-end revenue cycle functions means a lot of that hard work is already done, but not all of it. It also means that the effort can now be expended on improving clean claims submissions, patient experience outcomes, lowering delayed payment and denial rates and the other factors that cause cost and inefficiency issues within the revenue cycle.

 

Back Office Roles and Functions:

  • Claim submission and claim edit resolution
  • Payment posting
  • Credit balances and refund processing
  • Insurance accounts receivable follow-up
  • Denial resolution and appeals
  • Customer service and patient pay
  • Underpayment analysis and resolution
  • Core system management and reporting

Here are some of the critical back-end business office functions and best practice tips on how to organize your business office and add to your bottom line.

Claims submission and edit resolution tips:

  • Submit claims daily—The hard work in decreasing denial rates and days in A/R comes before the claim is even submitted. Staying timely and submitting new claims each day is best practice to ensure days in A/R are accurate and allows the appropriate amount of time to identify any mistakes that may be occurring prior to claims submission.
  • Work edits within 24 hours —Edit resolution is usually easy to work, and all edits should be worked within 24 hours. Failure to identify coding or charge entry mistakes prior to claims submission can result in claims being rejected by the payer. Establishing an internal process to work through edits and correct claims will decrease denial rates and produce healthy cash flow.
  • Maintain dedicated staff —This is easier said than done, but maintaining staff in the claim submission and edit resolution position is best practice due to the recurrent nature of some edits. A person who is very familiar with edits can resolve them quickly and recognize patterns that may indicate larger trends and issues.

Payment posting tips:

  • Automate as much as possible—90% of payment posting should be automated to minimize errors. Accurate payment posting is critical to overall profitability as well as ensuring patients are billed for the correct amounts. Accurately capturing denial reasons helps identify root cause.
  • Identify individual line denials—Payment posting consists of not only posting payments but also involves posting adjustments and denials. Since payers may deny an entire claim or just deny one line item on a claim, it’s important to have high attention to detail. It’s also impossible to retroactively find a denied line that is inadvertently included with the adjustment or part of the patient’s responsibility.
  • Be mindful of secondary and tertiary payers—Most billing systems will submit secondary claims electronically unless there are edits within the systems, but if the primary payment is posted with errors the secondary claim may go to the payer with mistakes.

Credit balances and refund processing tips:

  • Implement a proactive strategy—Work credits and issue refunds regularly to prevent them from becoming unmanageable, and negatively skewing performance data.
  • Issue refunds within 60 days—If refunds are sitting for more than two months, you will most likely find yourself with unhappy and confused patients. Patients receiving a credit check back from an account they thought was paid and closed can cause hassle and miscommunication— and creates a sense of mistrust among your patients.
  • Consider system automation to automatically apply patient credits to other services—Automatically applying credit balances to other services where appropriate cuts down on staff time needed to identify credit balances. An automated system may also help keep track of regulatory requirements to return/refund money to payers and patients.

Conceptual image of asphalt road and direction arrow

Insurance accounts receivable follow-up tips:

To maximize time spent, hire talented and dedicated specialists who are trained to follow up with insurers and thoroughly work claims—from denial to payment.  This role diligently follows up with claims that are processed incorrectly or not yet processed—20% of medical claims are processed incorrectly.

That’s 1 in every 5—which can significantly damage cash-flow.

Denial resolution and appeals tips:

  • Ensure claim report data is properly interpreted and denied claims are separated into ones that are preventable and ones that need to be managed when they occur.
  • Track denied claims for missing information—root cause analysis is necessary to determine how information gets missed.
  • Get focused and specific— for example, the denial may indicate a missing preauthorization/referral but looking into the specific payer details will help determine if your front-end staff failed to obtain the authorization or if the inaccurate information was specific to what that payer needed from the authorization when it was obtained. 

Customer service and patient pay tips:

  • Create productive contact at the right time with an educational approach to patient needs.
  • Use a propensity to pay a demographic aggregation tool to determine which patients are able to pay without multiple account touches to save time and resources.
  • Provide benchmarks and incentives for your patient experience representatives. Your staff wants consistency in expectations and they want to know they are doing a good job. Show your employees reports with trends that you are tracking in your organization and set goals for everyone. 

On the other side of the business office of back-end, roles include the patient experience representatives who follow up with your patients to collect payment and answer billing questions. For this role, you need team members who are committed to the patient experience and proficient with the insurance adjudication processes to help educate patients. It’s also important to have Supervisor and QA Analyst support to foster team member development.

Underpayment analysis and resolution tip :

Leverage technology to load fee schedules and automatically identify any variance. Also, you should regularly report to payers. According to an Emdeon study, payers underpay practices in the U.S by 7-11% on average.

This is not a trivial amount, but can often be overlooked and therefore the money is left on the table.

The bottom line

Back office roles and functions in the revenue cycle are critical to the success of your organization, and outsourcing these functions with a partner firm has many benefits—not the least of which is saving you and your people time and effort while improving revenue cycle performance. You’ll have access to potentially cost-prohibitive technologies to help achieve best practices, as well as resolve any difficulty with recruiting, retaining and educating qualified staff members.

Learn more about  The Necessity for Change: End-to-End Revenue Solutions

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Healthcare Consumerism: The Disconnect Between Knowing What Needs to Change and Putting a Strategy in Place to Get There

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Findings from Kaufman Hall’s 2018 Healthcare Consumerism Survey show a wide awareness among hospitals and health systems that consumer expectations are changing, and that hospitals need to focus on fulfilling those expectations. As one healthcare executive respondent commented: “We are assuming we know what [consumers] want, but I am not sure we do.”

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Tips to increase patient payments by followup

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Patient Payment

Tips To Recover Patient Payments

Collection of first 80% of payments is relatively easy as compare to the rest 20% which is most difficult part of collection.
For best control of Billing operations must consider these practices:

First of all, data you must need to register about a patient is – Patients name, address, phone numbers (home, work, and cell), employment information, social security numbers, and driver’s license number.
After this you must verify the patient’s eligibility for the benefit prior to the DOS (date of service). It can decrease the risk of writing off balances and also increase the cash flow of your business by decreasing the cost of collection. It can also help you to address co-pays and outstanding balances. Ensure that you have most updated patient information on hand by making an aligned process in place to review all billing forms.
Secondly, engage a patient after scheduling an appointment by reminder within 48 hours. It will reduce no-shows and ensure the opportunity of patient’ prompt arrival .It also minimize the risk of in-office disputes between the front office staff and the patient and improve the efficient productivity of practice.
Thirdly, setting the expectation of payments (EOPs) while scheduling appointment is an easy and effective way to prepare the patient for the expenses of services he is going to receive.
Fourthly, keep in mind when you should take the payment? I would suggest asking for payment details along with insurance information at the time of check in. It will reduce the cost of time needed to follow-up after patient’s checkout. This Tip will help improve cash flow of your practice.
Fifthly, take an extra step to make patients aware of what they are expected to pay for service when it comes to payment and billing. Here are some steps to follow.
• Make a written payment policy
• Provide a copy of written policy to patient and get it signed to ensure the receipt.
• Review and update patient forms annually.
• Ensure to get most current forms filled by patients.
• Train you staff using sample billing forms
Now on sixth step it comes with Patient payment follow-up to reduce slow pay or no pay accounts.
Check for rolling balance at 60-90 and 120 days which tells that there is still time left for patients to pay their due balances. Some patients don’t send payments. Send them statements without rolling balances and state that amount owed is a balance due. Statements should be sent at earlier stage to increase to chance of payments made is full and to enhance the cash flow of practice. Keep in mind that if patient is not aware of past due balance, it is more likely he would not pay it. Following are policies that most practices
should have:
• Patient Visit—Invoice at the point of sale- Signed credit application- Net 30 terms
• 14 Days – Statement- Interest and/or collection fees added at 30 days past due
• 30 Days – Monthly Statement
• 45 Days – Call- Phone call at 30 days past due
• 60- 90 Days – Turn them to collection agency

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The need of Bone mineral density test

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Bone mineral density test

Bone mineral density

To diagnose osteoporosis before a broken bone occurs, the only test is a bone density test, which can help to estimate the density of your bone. As recommended by National Osteoporosis foundation (NOF) a bone mineral density test of the hip and spin test is being done with central dexa (dual energy x-ray absorptiometry) machine.
Central dexa and peripheral tests are two types of bone density test.

A bone density test of the hip and spine using a central DXA machine to diagnose osteoporosis. When testing can’t be done on the hip and spine, National Osteoporosis foundation (NOF) suggests a central DXA test of the radius bone in the forearm. In some cases, the type of bone density testing equipment used depends on what is available in your community.
For example People of Larger Size. Most central DXA machines cannot measure bone density in the hip and spine of patients who weigh more than 300 pounds. Some newer machines can measure bone density in people who weigh up to 400 pounds, but these machines are not widely available. When the hip and spine cannot be measured, some healthcare providers recommend a central DXA test of the radius bone in the forearm and a peripheral bone density test of the heel or another bone.

Peripheral tests:
• pDXA (peripheral dual energy x-ray absorptiometry)
• pQCT (peripheral quantitative computed tomography)
• QUS (quantitative ultrasound)

These tests are very useful when central dexa is not available and also used to identify people who are more likely to get benefit from further bone density tests.

This test can be in-house from a healthcare provider or patient will be referred to a testing center. People taking an osteoporosis medicine should repeat their bone density test by central DXA every one to two years. After starting a new osteoporosis medicine, many healthcare providers will repeat a bone density test after one year.

T-score is used to determine whether a patient’s bone density is higher or lower than a standard bone density or 30 year old adult. To diagnose osteoporosis a provider looks at the lowest T-score.

• Normal -Bone density is within 1 SD (+1 or −1) of the young adult mean.

• Low bone mass- Bone density is between 1 and 2.5 SD below the young adult mean (−1 to −2.5 SD).

• Osteoporosis- Bone density is 2.5 SD or more below the young adult mean (−2.5 SD or lower).

• Severe (established) osteoporosis- Bone density is more than 2.5 SD below the young adult mean, and there have been one or more osteoporotic fractures.

The age-matched reading, known as the Z-score, compares a person’s bone density to what is expected in someone of equivalent age, sex, and size. However, among older and elderly adults, low bone mineral density is common, so comparison with age-matched norms can be misleading.

In addition to calculating Z-scores and T-scores, the DXA report may include a FRAX (fracture risk assessment tool) score. FRAX uses the bone density measurement, and other risk factors, to calculate a person’s risk of breaking any major bone or hip due to osteoporosis in the next 10 years. FRAX is used for those people who have not yet taken bone-building medication. If the probability of a hip fracture in the next 10 years is calculated to be more than 3%, or the probability of a fracture of any major bone due to osteoporosis is greater than 20%.

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Osteoporosis Causes, Prevention and Treatment

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Osteoporosis

Osteoporosis Causes, Prevention and Treatment

Osteoporosis

Osteoporosis (or porous bone) is a bone disease in which makes your bone extremely fragile and causes it to break easily. Without prevention or treatment, this disease can progress without pain or symptoms until a bone breaks (fractures).Worldwide more than 200 million people are suffering from osteoporosis.
Bones in your body are continuously broken down and reformed .The process is known as bone remodeling. Osteoporosis occurs due to an imbalance in this remodeling process. Special bone cells called “Osteoclasts” break down old bone. Then another type of bone cells called “Osteoblasts” creates new bone. In this disease more bone is broken down and less new bone is built back up. As a result, your bones become less dense (thick).

They lose their strength and start to break more easily. Calcium deficiency is the major cause of this desease. Low levels of calcium in your blood result in the release of a hormone that activates bone breaking cells. This is called a silent disease because bone weakening occurs over time and one cannot feel it. Breaking a bone is often the first sign of it.

The spine, hips, ribs and wrists are common areas of bone fractures.1 in 3 women and 1 in 5 men are Osteoporotic. It is more common among female after menopause. This is due to reduced levels of estrogen as a result of menopause. Menopause refers to the absence or menstrual periods for 12 months.

Smoking and excessive alcohol intake increases the risk of it. Genetics also plays a role in developing Osteoporosis. Up to 30 genes have been linked to the development of Osteoporosis. Lack of physical activity reduces bone and muscle strength which increases the risk of fractures and falls.

Osteoporosis is more or less preventable for most people. Prevention is very important because, while treatments for osteoporosis are in place, currently no cure exists. Prevention of osteoporosis involves several aspects, including nutrition, exercise, lifestyle, and, most importantly, early screening with bone density tests. Diet rich in Vitamin D and calcium can help prevent this disease. Vitamin D helps your body to absorb calcium and increases bone density.

Researchers are developing stem cell therapies to treat this disease. Stem cells from human amniotic fluid could be used to strengthen brittle bones.
The treatment resulted in 79% fewer fractures in mice with disease. Growth hormone (GH) taken with calcium and vitamin D supplements can also reduce the risk of fractures in the long term. Up to 75% of a person’s bone mineral density is determined by genetic factors. By identifying genes responsible for bone formation and loss. New techniques can be developed to prevent Osteoporosis in the future.

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Understanding of Metastasis or Advanced Cancer

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Metastasis or advanced cancer
Metastasis or advanced cancer
Metastasis or advanced cancer aka Stage 4 cancer

Stage 4 Cancer:
Also called as “Advanced Cancer “ or “Metastasis” is when cancer spreads to the different parts of the body. Metastasis develops when to cancer cells break away from the main tumor and enter the blood stream or lymphatic system. These systems carry fluids around the body. This is why cancer cells can then travel far from the original site of the tumor and form new tumors where they settle and grow in a different part of the body. this progression is also known as metastasis and unless a metastasis is singular—meaning that it has only spread in to one specific location—and it’s still accessible, it usually means that the cancer will no longer be curable with localized therapies such as surgery or radiotherapy.

“Metastasis depends on several factors, which include the type of cancer and its aggressiveness. And how long you had it before treatment”
Metastasis to the bones, brain, liver, lymph nodes, and lungs is common. Cancer cells can also metastasize to the linings around the lungs or the abdominal cavity. This may cause excess fluid buildup in these areas. Cancer can also spread to the skin, muscle, or other organs throughout the body. Doctors give a metastasis the same name as the original cancer.

So a breast cancer that spreads to the liver is referred to as “metastatic breast cancer” not liver cancer. Some cancers tend to spread to certain parts of the body. Here are some examples;

• Breast cancer spreads to the liver, bones, lungs, chest wall and brain.
• Lung cancer spreads to the brain, bones, liver and adrenal glands.
• Prostate cancer spread to the bones.

Treatment:
Treatment against cancer depends on several factors as well. The original cancer and where it started, how much the cancer has spread and where it is located. Most commonly doctor might try one type of chemotherapy and then switch to another when the first treatment no longer works. Or you might have a combination of treatments to remove the metastases. Such as chemotherapy, radiation, and/or surgery.
There are two main strategies when it comes to treatment|:

Systematic Therapy: Treating the entire body using chemotherapy and medication.

Local Therapy: Treating the area with cancer using surgery and radiation therapy.
In some cases, metastasis can be cured. But doctors use to slow its growth and reduce the symptoms. It is possible to live many months or even years with certain types of cancer even after the development of metastatic disease. It is important to ask your doctor about the goals of treatment. These goals may change during your care depending on whether the cancer responds to the treatment. It is also important to know that pain, nausea and other side effects can be managed with the help of your doctor.

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Understanding the Need of Botulinum Toxin Therapy

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Understanding the Need of Botulinum Toxin Therapy

Before we talk about coding and billing of Botulinum toxin therapy we should first understand the disorders diagnosed to be cured with this therapy. Neurologists provide skilled injection of botulinum toxin for the treatment of a variety of disorders that result in abnormal postures or movements.

Botulinum toxin may be used to treat:

  • Hemifacial spasm– Involuntary contraction of the muscles of the face on one side-injections around the eye and sometimes also the lower face can help.
  • Blepharospasm– Refers to spasming eyelids-Patients complain of repetitive blinking and sometimes, an inability to keep the eyes open. To treat this, very small amounts of botulinum toxin can be injected through a very fine needle into the eyelids. This partially paralyses the muscle and provides great relief.
  • Cervical dystonia/torticollis– Abnormally high muscle tone in the neck-may involve the neck being rotated and pulled in a certain direction or down towards the chest.
  • Spasticity– Cerebral palsy and stroke upper and lower limb, other cerebral and spinal disorders (e.g. multiple sclerosis);
  • Tremor– Unintentional trembling or shaking muscle movements involving one or more parts of the body. Most tremors occur in the hands but can also occur in the arms, head, face, vocal cords and legs.
  • Strabismus– known as crossed eyes, is a condition in which the eyes do not properly align with each other when looking at an object.
  • Spasmodic dysphonia– a neurological disorder affecting the voice muscles in the larynx, or voice box.
  • Headache- Tension and migraine– a severe throbbing pain or a pulsing sensation, usually on just one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound.
  • Orofacial Dyskinesias- Abnormal involuntary movements which primarily affect the extremities, trunk, or jaw that occur as a manifestation of an underlying disease process. Conditions which feature recurrent or persistent episodes of dyskinesia as a primary manifestation of disease may be referred to as dyskinesia syndromes

After initial consultation with a doctor to determine whether botulinum toxin is an appropriate treatment. an appointment will be scheduled during which the procedure will be re-explained and questions and concerns addressed.

Injections are performed in the office and the patient can go home afterward. A follow-up visit (in person or by telephone) is usually set up within two to three weeks to evaluate to results of the injection and discuss any side effects or concerns.

Botox may be better known as a tool for cosmetic surgeons, there are some conditions that are treated very effectively by botulinum toxin.Botox therapy is not a cure, it is an ongoing treatment used to manage your symptoms. For best results, oral medications in combination with therapy such as stretching and strengthening exercises are best and are typically the first line of treatment.

Botox Administration:

Botox is injected directly into muscles to block the connection between nerves and muscles in order to relieve spasms and other conditions associated with muscle over activity to treat dystonia. Once the physician is ready to administer the appropriate toxin injection, he will identify which muscle groups need to be injected. Doctors will select the muscles either by observing the abnormal postures or movements and feeling for the muscle spasm or by using an ultrasound, flouroscopy or electromyography (EMG) machine, which measures muscle activity.Patient discomfort is usually mild – in most cases, similar to a flu shot. Some people opt to take Tylenol or a mild sedative prior to the procedure.

 

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Nerve Conduction Studies and Electromyography Coding Tips

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Nerve Conduction Studies and Electromyography Coding Tips

As per AMA, the CPT book Definition of a conduction study is “defined as a sensory conduction test, a motor conduction test with or without an F wave test, or an H-reflex test.

Each type of study, sensory or motor with or without F wave, H-reflex associated with that nerve constitutes a distinct study when determining the number of studies in each grouping, eg. 1-2 or 3-4 nerve conduction studies.” With this coding definition, we can ID
the correct code.

The below Tips are based on most frequent examples of NCV with EMG coding and billing.

Identification of the correct code for NCV studies:

Count the number of motor and/or sensory studies done within each nerve. Example, the Right arms’ median, ulnar, and radial (motor and sensory) nerves are tested. We have 3 nerves with 2 studies in each nerve. This would yield a total of 6 studies (3×2). CPT code is 95909.

Coding for bilateral NCV study:

Using the same example above, I would count each nerve (with study) on both extremities. Motor and Sensory studies in bilateral upper extremities on each three nerves would yield 12 studies; CPT code 95912.

Tip: Look for the terms “motor” and “sensory” (F wave and H-reflex are included and not separately counted). ID the number of nerve(s) tested, then count each motor and sensory test done on each nerve. Don’t forget if it’s done bilaterally to also count that as it can affect the code selection. If it’s a mirror image of the opposite limb, just duplicate that initial limb findings.

Some time we caught with a situation where we think, Can we count the study more than once when performed along the same nerve?

Simply put, NO.

The coding guidelines state “each type of NCV study is counted only once when multiple sites on the same nerve are stimulated or recorded.

Tip: Paraspinal nerves tested within the affected limb are not coded separately as they are included in the NCV code parental description. Paraspinal nerves tested NOT ASSOCIATED with that limb can be separately code (if medical necessity supports) with codes (95860-95864 and 95867-95870).

For example: A neurologist performed a one limb EMG (6 muscles) without any NCV on the same day. Because no NCVs were performed that day on that patient, the old Code 95860 ( Needle Electromyography; 1 extremity with or without related paraspinal areas) should be used.

Identification of the correct code for EMG done with NCV studies:

Use code 95885 when a limited (less than five muscles) are studied within a limb or use code 95886 when a complete (five or more muscles) are studied.

Count the number of muscles for each extremity; if all extremities studied are complete use CPT 95886 once with 4 units.If only two extremities are a complete study and the other two extremities are a limited study, then code 95886×2 units for the complete and 95885×2 units with modifier 59 for the limited.

Tip: Both the printout of the study and the provider’s interpretation with report should mention the number of muscles tested on each limb. The term “all other muscles” without the actual documentation support (either in the printout or report) should not be used to support a higher (95886) code.

Here I am going to summaries my article for easy understanding:

NCV STUDIES:

• 3 Nerves: Median, Ulnar, radial nerves (Studies: Motor and Sensory) ,we have 3 nerves with 2 studies in each nerve this would yield a total of 6 studies (3×2) CPT 95909.
• In case of bilateral studies; I would count in same fashion above, and count it as 12 studies and cpt would be 95912 (note: it’s a mirror image of the opposite limb, just duplicate the initial limb)
• I would not count the study more than once when performed on the same nerve.
• Para spinal nerves tested within the effected limb are not coded separately.
• Para spinal nerves not associated with the limb can be coded separately; with code 95870.

EMG STUDIES:

• Use code 95885 when a limited study performed ( less than 5 muscles)
• Use code 95886 when a complete study performed (five or more muscles)
• Count the number of muscles for each extremity; if all extremities studied are complete use CPT 95886 once with 4 units .
• If only two extremities are complete and two are limited, then use code 95886 x 2 units and 95585 x 2 units..Use 59 modifier for the limited .

Note: The term all other muscles “without the actual documentation support”, should not b used to support a higher code.

Real life example of counting nerve and muscles to code ncv and emg.

 

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