CONTINUUM: Lifelong Learning in Neurology:
doi: 10.1212/01.CON.0000411561.95967.53
Practice Issues

Coding Issues

Donofrio, Peter D. MD, FAAN

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Author Information

Address correspondence to Dr Peter D. Donofrio, Vanderbilt University Medical Center North, AA0204B, Nashville, TN 37232, peter.donofrio@vanderbilt.edu.

Relationship Disclosure: Dr Donofrio serves on the scientific advisory boards of CaridianBCT, Inc., CSL Behring, DiME, and Talecris Biotherapeutics, and has also participated in medical legal case reviews.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Donofrio reports no disclosure.

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Abstract

Accurate coding is an important function of neurologic practice. This section of CONTINUUM, contributed by members of the AAN Medical Economics and Management Committee, includes helpful coding information and examples related to the issue topic. This section may include diagnosis coding, evaluation and management coding, procedure coding, or a combination, depending on which is most useful for the subject area of the issue.

To operate a financially profitable neurologic practice, accurate coding is necessary for billing and reimbursement. Claim denials are costly because reimbursement is delayed and sometimes not recoverable. This coding issues section is composed to aid in the proper use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and procedural codes for patients with peripheral neuropathy. This article will not address evaluation and management codes used for billing patient encounters in the outpatient and inpatient setting.

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ICD-9-CM CODES FOR PERIPHERAL NEUROPATHY

Disorders of the Peripheral Nervous System (350–359)

353 Nerve Root and Plexus Disorders

353.0 Brachial plexus lesions

 Thoracic outlet syndrome

Exclude:

 brachial neuritis or radiculitis NOS (723.4)

 that in newborn (767.6)

353.1 Lumbosacral plexus lesions

356 Hereditary and Idiopathic Peripheral Neuropathy

356.0 Hereditary peripheral neuropathy

 Dejerine-Sottas disease

356.1 Peroneal muscular atrophy

 Charcot-Marie-Tooth disease

 Neuropathic muscular atrophy

356.2 Hereditary sensory neuropathy

356.3 Refsum’s disease

 Heredopathia atactica polyneuritiformis

356.4 Idiopathic progressive polyneuropathy

356.8 Other specified idiopathic peripheral neuropathy

356.9 Unspecified

357 Inflammatory and Toxic Neuropathy

357.0 Acute infective polyneuritis

 Guillain-Barre syndrome

 Postinfectious polyneuritis

357.1 Polyneuropathy in collagen vascular disease

Note: Code first underlying disease, as:

 disseminated lupus erythematosus (710.0)

 polyarteritis nodosa (446.0)

 rheumatoid arthritis (714.0)

357.2 Polyneuropathy in diabetes

Note: Code first underlying disease (249.6, 250.6)

357.3 Polyneuropathy in malignant disease

Note: Code first underlying disease (140.0–208.9)

357.4 Polyneuropathy in other diseases classified elsewhere

Note: Code first underlying disease, as:

 amyloidosis (277.30–277.39)

 beriberi (265.0)

 chronic uremia (585.9)

 deficiency of B vitamins (266.0–266.9)

 diphtheria (032.0–032.9)

 hypoglycemia (251.2)

 pellagra (265.2)

 porphyria (277.1)

 sarcoidosis (135)

 uremia NOS (586)

357.5 Alcoholic polyneuropathy

357.6 Polyneuropathy due to drugs

Note: Use additional E code to identify drug.

357.7 Polyneuropathy due to other toxic agents

Note: Use additional E code to identify toxic agent.

357.8 Other inflammatory and toxic neuropathy

 357.81 Chronic inflammatory demyelinating polyneuritis

 357.82 Critical illness polyneuropathy

 Acute motor neuropathy

 357.89 Other inflammatory and toxic neuropathy

357.9 Unspecified inflammatory and toxic neuropathies

334 Spinocerebellar Disease

Exclude:

 olivopontocerebellar degeneration (333.0)

 peroneal muscular atrophy (356.1)

334.0 Friedreich’s ataxia

334.1 Hereditary spastic paraplegia

336 Other Diseases of Spinal Cord

336.2 Subacute combined degeneration of spinal cord in diseases classified elsewhere

Note: Code first underlying disease, as:

 pernicious anemia (281.0)

 other vitamin B12 deficiency anemia (281.1)

 vitamin B12 deficiency (266.2)

337 Disorders of the Autonomic Nervous System

Include: disorders of the peripheral autonomic, sympathetic, parasympathetic, or vegetative system

Exclude: familial dysautonomia (Riley-Day syndrome) (742.8)

337.0 Idiopathic peripheral autonomic neuropathy

 337.00 Idiopathic peripheral autonomic neuropathy, unspecified

 337.09 Other idiopathic peripheral autonomic neuropathy

 Cervical sympathetic dystrophy or paralysis

337.1 Peripheral autonomic neuropathy in disorders classified elsewhere

Note: Code first underlying disease, as:

 amyloidosis (277.30–277.39)

 diabetes (249.6, 250.6)

782 Symptoms Involving Skin and Other Integumentary Tissue

Exclude: symptoms relating to breast (611.71–611.79)

782.0 Disturbance of skin sensation

 anesthesia of skin

 burning or prickling sensation

 hyperesthesia

 hypoesthesia

 numbness

 paresthesia

 tingling

Several coding issues are apparent when reviewing the ICD-9-CM codes listed above. Essentially all peripheral neuropathies can be coded using one of the ICD-9-CM codes listed. Coding for diabetic neuropathy requires the use of two codes, 250.6 for a neurologic complication of diabetes followed by 357.2 for diabetic neuropathy. This use of two codes also applies to other polyneuropathies that arise from an underlying systemic disease, poisoning, or drug. Thus, to code for a polyneuropathy due to systemic lupus erythematosus, one would first record 710.0 for lupus and follow this with the code 357.1 for polyneuropathy arising from a collagen vascular disease. Similarly, to code for arsenic-induced neuropathy, one would use the E code for arsenic poisoning, E866.3, and subsequently 357.7 for polyneuropathy due to other toxic agents.

A specific code for polyneuropathy should not be used unless the diagnosis has been established. For instance, if a patient reports burning, numbness, paresthesia, and tingling in the feet but the clinician is not certain the patient has a polyneuropathy, the ICD-9-CM code 782.0 for disturbance of skin sensation should be used instead of a code for a specific diagnosis of polyneuropathy that may not be substantiated. Using a symptom code is a common practice in the EMG lab when a patient is referred for evaluation of a polyneuropathy but nerve conduction studies do not support a diagnosis of polyneuropathy. The same code is used for patients who are referred to the EMG lab for evaluation of carpal tunnel syndrome or ulnar neuropathy and the electrophysiologic studies are normal.

ICD-9-CM will not be used for disease coding after October 1, 2013, when it will be replaced by ICD-10. ICD-10 has been used in Europe for more than 15 years and is a more versatile and extensive coding system. It uses an alphanumeric code for diseases rather than the three to five numbers used in the ICD-9-CM system. ICD-10 will have the capability to code for 67,000 diseases. It will be make adding new disease codes easier, permit more accurate reimbursement for procedures, be more comprehensive in reporting quality data, and allow the United States to compare its disease incidence data to that of other countries.

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CURRENT PROCEDURAL TERMINOLOGY CODES FOR PERIPHERAL NEUROPATHY

Traditional Nerve Conduction Studies and F Wave Testing

Coding for nerve conduction studies should be relatively easy because specific codes exist for motor nerve conduction studies with and without F waves and for sensory and mixed studies.

95900 Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study

95903 Nerve conduction, amplitude and latency/velocity study, each nerve; motor, with F-wave study

95904 Nerve conduction, amplitude and latency/velocity study, each nerve; sensory

What constitutes a nerve for billing purposes can be found in Appendix J of the Current Procedural Terminology (CPT) Codebook.

Appendix J lists nerves by stimulation and recording sites. This permits one to test the same nerve, yet record and stimulate in different areas, and bill for another nerve. An example is the peroneal motor nerve recording from the extensor digitorum brevis and later at the tibialis anterior muscle. Another example would be the separate listing for median sensory studies of the thumb, index, middle, and ring fingers. In the latter case, one would bill multiple units for median sensory testing of those four digits.

Below is an excerpt from Appendix J of the CPT Codebook for nerves in the forearm and hand. Each constitutes a separate nerve for billing purposes.

A. Lateral antebrachial cutaneous sensory nerve

B. Medial antebrachial cutaneous sensory nerve

C. Medial brachial cutaneous sensory nerve

D. Median nerve

1. Median sensory nerve to the first digit

2. Median sensory nerve to the second digit

3. Median sensory nerve to the third digit

4. Median sensory nerve to the fourth digit

5. Median palmar cutaneous sensory nerve

6. Median palmar mixed nerve

E. Posterior antebrachial cutaneous sensory nerve

Note that codes 95900, 95903, and 95904 are only billed once per nerve when multiple sites are stimulated and the recording site remains the same. For example, one can only bill code 95900 once for an ulnar motor nerve study when the nerve is stimulated at the wrist, below and above the elbow, at the axilla, and at Erb point. A CPT code does not exist for inching studies of motor nerve. One cannot bill additionally for an inching study once the initial motor study has been completed.

Some payers reject code 95900 and code 95903 whenever they are reported together, as their coders interpret the billing of 95900 as a component code of 95903. This should not create a problem if the billing is displayed such that there are separate entries for 95900 and 95903. If the billing is challenged, then a letter can be sent to the payer explaining the performance of motor nerve conduction studies without F waves on some nerves and with F-waves on other nerves. Component billing (ie, billing 95900 and 95903 for the same nerve) is not allowable.

A mixed nerve contains motor and sensory nerve fibers and is billed as a sensory nerve using code 95904. An example of testing a mixed nerve is orthodromic stimulation of the median nerve at the wrist.

H Reflex Testing

95934 H-reflex, amplitude and latency study; record gastrocnemius/soleusmuscle

94936 H-reflex, amplitude and latency study; record muscle other than gastrocnemius/soleus muscle

H reflex codes are defined as unilateral studies. To report a bilateral study, one must use the modifier 50. It is not acceptable to bill for two units of the H reflex code for bilateral studies.

Electromyography of Limbs

95860 Needle electromyography; one extremity with or without related paraspinal areas

95861 Needle electromyography; two extremities with or without related paraspinal areas

95863 Needle electromyography; three extremities with or without related paraspinal areas

95864 Needle electromyography; four extremities with or without related paraspinal areas

95869 Needle electromyography; thoracic paraspinalmuscles (excluding T1 or T12)

95870 Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters

To bill for a full limb EMG, the electromyographer must evaluate extremity muscles innervated by three nerves or four spinal levels, and a minimum of five muscles per limb must be studied. Paraspinal muscles do not count toward the five muscle total.

Use code 95869 when exclusively studying the thoracic paraspinal muscles, excluding T1 or T12. One unit would be billed regardless of the number of levels sampled or whether the testing was unilateral or bilateral. One cannot bill 95869 with codes 95860–95864 if an upper limb is tested and the T1 paraspinal muscle is added to the cervical paraspinal muscles sampled. The same concept applies to using 95869 when the T12 paraspinal muscles are sampled in an evaluation of a lumbosacral radiculopathy. Coding for 95870 for muscles of the thorax or abdomen (unilateral or bilateral) is applied in the same manner.

Somatosensory-Evoked Potentials

95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs

95926 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs

95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head

Codes 95925–95927 (somatosensory-evoked potentials [SSEPs]) cannot be billed more than one time each on the same patient during the same session. Those same three codes can be reported together if performed during the same session. The coding for SSEPs is bundled such that 95925 or 95926 is billed once per session regardless of the number of nerves studied in a limb. Studies must be done bilaterally, which makes sense because the strength of the interpretation lies in comparison of one side to the contralateral side. Studies of the trunk and head must also be performed bilaterally to bill for code 95927. Formerly, one could bill one SSEP code for each nerve tested.

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ADDITIONAL RESOURCES

Abraham M, Ahlman JT, Boudreau AJ, et al; American Medical Association. 2011 CPT (Current procedural terminology). Standard edition. Chicago: American Medical Association Press, 2010.
Powers LB, Tardo C; American Academy of Neurology. International classification of diseases (ICD)-9-CM 2011 for neurologists. St. Paul, MN: American Academy of Neurology, 2010.

© 2012 American Academy of Neurology

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