Billing and Coding: Nerve Conduction Studies and Electromyography

S , v ( ) n t b items extracted_text extraction_notes Usually an E&M service is included in the exam performed just prior to and during nerve conduction studies and/or electromyography. If the E&M service is a separate and identifiable service, the medical record must document medical necessity and the CPT code must be billed with a modifier 25. The clinical history from the referral source must indicate the need for testing. These medical records containing pertinent clinical information must be provided for review on request. g N C In some situations it may be necessary to test an asymptomatic contralateral limb to establish normative values for an individual patient. Documentation must support the medical necessity of the additional test. In the small number of cases which require testing in excess of the numbers listed in the table, the physician must be able to provide supplementary documentation to justify the additional testing. When this study is performed, the physician's report must document characteristics of the test, including the rate of repetition of stimulations, and any significant incremental or decremental response. The report of this study should include the presence or absence of the R1 and R2 components. Narrative reports alluding to "normal" or “abnormal" results without supporting numerical data. Descriptions of F-wave without reference to corresponding motor conduction data; pattern-setting unilateral H-reflex measurements; separate E/M charges without documentation requested from the referral source. Failure to submit, upon request or when requesting a review, a clinical history indicating the need for testing. Absence of a clinical history, preferably written by the referral source, indicating the need for the test. Absence of documentation to support repeated testing on the same beneficiary. * D o c u m e a i R q r s T h p ' d l y f . I w