Comparative Billing Reports

CBR201602 Electrodiagnostic Testing (EDX) FAQs

Question Categories:

General

Clinical and Billing

Report Specifics

 

 

General

 

What is the purpose of this comparative billing report (CBR)?

The purpose of CBR201602 is to inform providers about their billing and payment patterns of EDX testing for Medicare beneficiaries. This CBR provides education and information to assist providers with identifying and correcting billing errors. The CBR team reviewed only Fee-for-Service Medicare (Original Medicare) claims of providers who billed for these services. For more information about CBRs, please visit our website link titled, Comparative Billing Reports.

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What are the Current Procedural Terminology (CPT®) codes included in this CBR?

The CPT® codes included in this CBR are:

• CPT® 95860-95870 (Electromyography or EMG)

• CPT® 95905-95913 (Sensory Nerve Conduction Threshold Tests)

• CPT® 95885-95887 (EMG and NCS)

Please refer to the CPT® 2014 and 2015 Professional Edition manuals for complete descriptions of the CPT® codes, which can be accessed from the American Medical Association (AMA) website at the link, AMA Store.

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How many providers received CBR letters?

After claims were pulled and the data evaluated for the CPT® codes listed above, CBRs were sent to approximately 4,300 Medicare Part B providers. The CBR contains a provider’s billing history and patterns and compares them to his/her peers.  A mock provider’s CBR can be reviewed at the following link: CBR201602 Sample CBR.

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Why was this topic selected for a CBR?

CBR201602 is a follow-up to our original EDX testing CBR from 2014 (CBR201406). Our first CBR on EDX testing was based on an Office of Inspector General (OIG) report, which found that EDX testing was an area vulnerable to fraud, waste, and abuse. Since it’s been more than a year since the first CBR, the Centers for Medicare & Medicaid Services (CMS) has requested a repeat CBR to determine if the billing and payment patterns of providers have changed. The first EDX testing webinar is accessible at the following link: CBR201406 Webinar Recording.

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What is the specific focus of CBR201602?

CBR201602 focuses on providers that perform nerve conduction studies (NCS) and needle electromyography (EMG) on beneficiaries covered by Original Medicare. The report examines the average allowed charges per beneficiary, the average weighted services by category, and the percentage of visits with NCS. If you did not receive a CBR letter and wish to review a sample of a mock provider, please visit the CBR website at the following link: CBR201602 Sample CBR.

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Does receiving a CBR mean that I am billing incorrectly?

No. Receiving a CBR does not mean that claims are being billed incorrectly; however, it does mean that your billing is different from your peers. We recognize that practice and billing patterns of providers differ for a number of reasons and can vary by region, subspecialty, and patient acuity, which are elements that are not evident in the claims data reviewed for the CBR. Our goal is to assist providers with understanding Medicare billing and coverage guidelines; however, providers should remember they are ultimately responsible for knowing Medicare coverage criteria and incorporating correct billing and coding practices. The CBR Support Help Desk is available to respond to any questions and/or concerns and can be contacted by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.

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Will providers be audited based on the results of the CBR?

No. Providers will not be audited by the CBR team, as we do not perform any audits.  Additionally, we do not have access to your review medical records. The purpose of the CBR is to allow a provider to compare his/her billing patterns to those of his/her peers; however, it may be beneficial for providers to conduct self-audits. For resources that can help with setting up an audit process, please visit our CBR website page at the link titled, Self-Audit Help.

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Are there other references and resources available about EDX testing?

Yes. Providers may benefit from additional information available on our CBR website. A description of the Tables used in this CBR can be found at the link, CBR201602 Statistical Debriefing.

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Clinical and Billing

 

What is involved in EDX test?

EDX tests measure the degree of electrical activity in a patient’s muscles and nerves. With this testing, doctors are able to determine if there is nerve damage, the cause of the damage, and whether or not the damaged nerve is responding to treatment. The typical evaluation includes a history and physical examination by the doctor, a working diagnosis, and the design, performance, and interpretation of NCS and EMG studies. An EDX evaluation usually takes a minimum of 30 minutes to perform, but can take up to two hours or more, depending on the situation.

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Who is considered to be an appropriate provider for performing and/or interpreting EDX testing?

It is best to contact your MAC since the training and credentials needed are different for some regions; however, the majority of MACs require formal residency/fellowship program, certification by a nationally recognized organization, and/or accredited post-graduate training covering anatomy, neurophysiology, nerve conduction studies, and electromyography. There are MACs, however, that place no restrictions on the specialty of physicians performing EDX tests, except for an Independent Diagnostic Testing Facility (IDTF). AANEM believes that EDX evaluations should be done by neurologists or physiatrists who have special training in diagnosing and treating neuromuscular diseases and disorders.

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Is an EDX test considered to be a standard test like an electrocardiogram (EKG)?

No. The EDX testing physician has to continually reassess the findings during testing and may have to modify the initial study to include other unplanned procedures; EKG testing involves a technician recording a set protocol for later interpretation by the physician.

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What is included in NCS testing and what does it show?

NCS tests are often conducted along with the EMG to determine how well a patient’s nerves are functioning. The doctor tapes wires (electrodes) to the skin, applies small electrical shocks to the nerves, and records how the nerves are functioning. By stimulating the nerves of different muscles, the doctor is able to interpret the studies (in real time) as they are being performed. According to the model policy of the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM), the typical EDX examination includes the “development of a differential diagnosis by the EDX physician, based upon appropriate history and physical examination and the referring physician’s concerns...” 

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Is a NCS alone covered by Medicare?

No. Medicare considers NCS alone a screening exam, which is usually not covered by Medicare; however, one exception is an NCS performed for carpal tunnel syndrome.

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What are Medically Unlikely Edits (MUE)?

MUE stands for medically unlikely edits, which is a unit of service CMS developed to reduce the paid claims error rate for Part B services. If you need additional information regarding MUE, please see the MLN Matters® educational resource at the following link:  Medically Unlikely Edits (MUE) and Bilateral Procedures.

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What are the CPT® codes and maximum units of service (UOS), per the MUE tables, for NCS tests?

Below is a list of the CPT® codes, abbreviated descriptions, and the UOS per MUE for NCS.

• 95905 – Motor and/or sensory nerve conduction, using preconfigured electrode array(s)

  • UOS per MUE – 2

• 95907 – Nerve conduction studies; 1-2 studies

  • UOS per MUE – 1

• 95908 – Nerve conduction studies; 3-4 studies

  •  UOS per MUE – 1

• 95909 – Nerve conduction studies; 5-6 studies

  •  UOS per MUE – 1

• 95910 – Nerve conduction studies; 7-8 studies

  •  UOS per MUE – 1

• 95911 – Nerve conduction studies; 9-10 studies

  •  UOS per MUE – 1

• 95912 – Nerve conduction studies; 11-12 studies

  •  UOS per MUE – 1

• 95913 – Nerve conduction studies; 13 or more studies

  •  UOS per MUE – 1

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What happens during a needle electromyography (EMG) test?

During the EMG test, the doctor places small, thin needles in the muscles of the patient to record electrical activity. The doctor is able to see and hear the electrical signal made by the muscles and uses this information to determine the cause of the problem. EMG tests are done to exclude, diagnose, describe, and follow diseases of the peripheral nervous system and muscle..

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What are the CPT® codes and maximum UOS, per the MUE tables, for EMG tests?

Below is a list of the CPT® codes, abbreviated descriptions, and the UOS per MUE for EMG.

• 95860 – Needle EMG; 1 extremity with or w/o related paraspinal areas

  • UOS per MUE – 1

• 95861 – Needle EMG; 2 extremities with or w/o related paraspinal areas

  • UOS per MUE – 1

• 95863 – Needle EMG; 3 extremities with or w/o related paraspinal areas

  •  UOS per MUE – 1

• 95864 – Needle EMG; 4 extremities with or w/o related paraspinal areas

  •  UOS per MUE – 1

• 95865 – Needle EMG; larynx

  •  UOS per MUE – 1

• 95866 – Needle EMG; hemidiaphragm

  •  UOS per MUE – 1

• 95867 – Needle EMG; cranial nerve supplied muscle(s) unilateral

  •  UOS per MUE – 1

• 95868 – Needle EMG; cranial nerve supplied muscle(s) bilateral

  •  UOS per MUE – 1

• 95869 – Needle EMG; thoracic paraspinal muscles (excluding T1 or T12)

  •  UOS per MUE – 1

• 95870 – Needle EMG; limited study of muscles in one extremity or non-limb muscles (unilateral or bilateral)

  •  UOS per MUE – N/A

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Does Medicare cover the Sensory Nerve Conduction Threshold Tests (sNCT)?

No, Medicare does not cover this service. Medicare does not consider this service reasonable and necessary within the parameters of section 1862 (a) (1) (A) of the Social Security Act. This testing should be billed with CPT® code G0255, not with CPT® codes 95905-95913.

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What should be included in the patient’s record to document EDX testing?

You can get a good idea of the documentation needed for EDX claims from the guidelines of Palmetto GBA.  LCD L35048 states, “The electrodiagnostic evaluation is an extension of the neurologic portion of the history and physical examination. Both require a detailed knowledge of a patient and his/her disease…The patient’s medical records must clearly document the medical necessity for the test, including a brief history and exam that ensures the individual(s) that perform/interpret the study do so with adequate knowledge of essential presenting criteria.”

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Report Specifics

 

How were allowed charges calculated in this CBR?

Allowed charges for this CBR were calculated based on the Medicare Physician Fee Schedule (MPFS). Payment can vary depending on the carrier locality, the type of facility in which the service was rendered, the number of units billed, and the use of a modifier. In most instances, Medicare pays the provider 80 percent of the fee schedule allowed amount, and the patient is responsible for the balance of the payment; however, there are some exceptions to this rule. CMS has a database that provides payment information for covered services.

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My allowed charges are higher than the national averages. Are my allowed charges being compared to providers in other states that have lower allowed charges?

Medicare Physician Fee Schedule (MPFS) allowed amounts vary from area to area. While we understand that these differences may affect your average allowed charges per beneficiary, these comparisons are provided so that you may get a better idea of where you stand in comparison to the nation as a whole, and to providers in your specialty. If you know that your area has higher allowed charges than the national average, then a higher average would not necessarily indicate any wrong-doing.  A geographic practice cost index (GPCI) has been established to account for the variation in practice expenses across the states and nation.

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What do the comparison outcomes mean?

The four possible outcomes for the comparisons between the provider and peer groups are:

• Significantly Higher - provider’s value is higher than the value of the peer value and the statistical test used confirms significance

• Higher - provider’s value is higher than the peer value but either the statistical test does not confirm significance or there is insufficient data for comparison

• Does Not Exceed - provider’s value is not higher than the peer value

• N/A (Not applicable) - provider does not have sufficient data for comparison

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Can you explain what Table 1 means?

Table 1 is a Summary of Your Utilization of the CPT® codes used in this CBR. To help illustrate Table 1, see the mock provider’s sample CBR at the link, CBR201602 Sample CBR. The first column lists the CPT® codes included in this analysis. The second column provides the Category of the CPT® code (NCS, EMG, or combined NCS & EMG). The next column provides a short Description of the CPT® code. Finally, the last three columns provide the Allowed Charges, Allowed Services, and distinct Beneficiary Count for each CPT® code.

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What does Table 2 mean?

Table 2 is an example of the analysis of the Average Allowed Charges per Beneficiary. To help illustrate this, refer to Table 2 of the mock provider’s sample at the link, CBR201602 Sample CBR. In this example, the provider’s average allowed charges were $274.51. His specialty’s average is $299.72, and the national average is $303.53. This provider’s percentage Does Not Exceed either his specialty’s average or the national average allowed charges per beneficiary. The results for each state and the nation can be viewed at the link, CBR201602 Statistical Debriefing.

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What does Table 3 mean?

Table 3 is an example of the analysis of Average Weighted Services per Beneficiary. For an illustration, please reference Table 3 of the mock provider’s CBR on our website a the link: CBR201602 Sample CBR. In this example, the averages are calculated for each category. The provider has an average of 8.44 services for claims submitted under the NCS category, 1.00 for EMG services, and 1.56 for Combined NCS & EMG services. This provider’s average number of services per beneficiary was Higher than his specialty and national averages for the NCS category. However, the provider’s average number of services Does Not Exceed either his specialty or the nation in the other two categories (EMG and combined NCS & EMG). To view the results for each state and the nation, see the following link: CBR201602 Statistical Debriefing.

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What does Table 4 mean?

Table 4 is an example of the results of the analysis of the Percentage of Visits with Only NCS CPT® Codes. For an illustration, please reference Table 4 of the mock provider’s CBR on our website at the link, CBR201602 Sample CBR. In this example, the provider had 27 percent of his total visits counted as a NCS only visit. This was Significantly Higher than his specialty’s average of 7 percent and also Significantly Higher than the national average at 10 percent. To review the results of each state and the nation, see the following link: CBR201602 Statistical Debriefing.