Medicare is consistently denying the H reflex study "95934" modifier 50 for bilateral, when billed with 95900 and 95904 H reflex is done to diagnose radiculopathies. I have appealed and been paid, but is there a way to bill so I don't have to always appeal these ???
Sheila
Radiculopathy evaluation needs at least one motor, one sensory nerve conduction study, and a needle EMG examination of the involved limb(s). The combination of codes may not be the problem. CPT directs you to report a bilateral H-reflex study with 95934-50. You can try with the LT & RT modifiers. If that does not work, then the best you can do is to clarify with the payer on how they want it to be billed.
There's no problem in reporting the 3 codes together. Though, Medicare should accept bilateral procedures with modifier 50 only, it is better to discuss with the local MAC in order to know which is their preferred way of reporting this incident -- with modifier 50 or, with modifier LT & RT (95934 codes in 2 different lines), to avert future repetitive denials. Following are a few notes from the CPT Assistant (various editions) related to the code 95934. Hope this helps.
1) "H-reflex studies are entirely separate tests from F-wave studies. H-reflex studies involve both the sensory and motor nerves. They assess sensory and motor nerve function and their connections in the spinal cord. An impulse, generated at the stimulating electrode, travels up the axons of sensory nerves then to the spinal cord, where it crosses a synapse and activates motor neurons. The impulse then travels down the motor nerves to the neuromuscular junction, and then to the muscle.
H-reflex studies usually involve assessment of the tibial motor nerve and the gastrocnemius-soleus muscle complex, and are not often performed in conjunction with conventional nerve conduction studies of this nerve-muscle pair. Although additional H-reflex studies of other muscles are occasionally indicated, typically only one or two H-reflex studies are performed on a patient during a given encounter. Bilateral gastrocnemius-soleus H-reflex abnormalities are often early indications of spinal stenosis, bilateral SI radiculopathies, and peripheral polyneuropathies."
2) "CPT codes 95934 and 95936 represent unilateral procedures and are intended to be reported per study. H-reflex studies must often be performed bilaterally. Bilateral studies are indicated when an abnormal response is found in a unilaterally symptomatic limb or when there is a question that the response could be abnormal for reasons other than pathology, such as advanced age.
When a bilateral H-reflex study is performed, the entire procedure must be repeated, increasing examiner time and effort. A bilateral H-reflex study would be reported by appending Modifier -50, Bilateral Procedure, to the CPT code reported."
Denials for CPT 95934 can also be due to some specific ICD codes accepted by your payer, like for example Cigna accepts (724.00-724.02, 724.1, 724.3-724.4) for radiculopathy. The clinical history and examination, carried out before the study, must always describe and document clearly and comprehensibly the need for the planned test, and what the results are expected to contribute that is medically necessary for the ordering physician to diagnose or treat the illness or injury or improve the functioning of a malformed body member.
CPT 95934 can be reimbursed only once per nerve, or named branch of a nerve, regardless of the number of sites tested or the number of methods used on that nerve. For instance, testing the ulnar nerve at wrist, forearm, below elbow, above elbow, axilla and supraclavicular regions will all be considered as a single unit test of code 95900 or 95903.
Generally, Medicare pays two time per year for code 95934 and payment for additional tests will require medical record review during a requested redetermination.
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