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A few years ago, Thomas C. Chelimsky, MD, Associate Professor of Neurology at the University Hospitals of Cleveland, first realized that the three separate codes of the autonomic nervous system – “cardiovagal innervation” (95921), “vasomotor adrenergic function” (95922), and “sudomotor” (95923) – were being “bundled” by the Health Care Financing Administration (HCFA), since renamed the Centers for Medicare & Medicaid Services (CMS). The policy meant that neurologists were being paid for only one of the procedures on a given day. He contacted the AAN Medical Economics and Management (MEM) Subcommittee and a letter was drafted to HCFA by the following day. It was indeed an error and the bundling was quickly reversed, allowing billing of all three procedures on one day, as they are often performed. (See sidebar, New Codes for Billing.)

“When I called MEM, I was told that although the codes had been in effect since 1997, no one had reported the error before,” said Dr. Chelimsky.

“Don't assume that anyone is aware of the particular problem you are having with reimbursement, even if it is related to a national policy,” he said. ''Moreover, don't assume that we have such a cumbersome system that nothing can be done about it.

“MEM was helpful and responsive and, consequently, instead of getting paid about 12 percent of what we were due,” he added, “we are now able to recover the entire allotted amounts.”

Furthermore, as private carriers adopt CMS policies, the cumulative financial consequences may have a major impact on a practice's bottom line.


P. David Charles, MD, Director of the Movement Disorders Clinic at Vanderbilt University Medical Center in Nashville, TN, encountered a more difficult problem. There was a consensus among providers that reimbursement for deep brain stimulation (DBS) programming was undervalued.


Dr. Orly Avitzur is a neurologist in private practice in Tarrytown, NY. She holds joint academic appointments at Yale University School of Medicine and New York Medical College.

“It was lumped into a category defined as any neurostimulator, which did not adequately characterize the procedure,” he explained. MEM was contacted to investigate the matter and after accumulating detailed data on how much time it took to perform the programming and how complex it was in comparison to other types of work, the subcommittee applied to the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel to create new codes.

“Although the codes were approved, we are now waiting to hear if CMS takes the recommendation from AMA's Relative Value Update Committee (RUC),” explained Dr. Charles. RUC advises on physician reimbursement values and the Practice Expense Advisory Committee (PEAC) advises CMS on standards for practice expenses.

“Physicians are often guilty of complaining bitterly and doing nothing,” Dr. Charles said, “but there is a process by which we can effect change. It is typically bureaucratic, but it works.”


Charles H. Tegeler, MD, Professor of Neurology at Wake Forest University School of Medicine in Winston-Salem, NC, and Past-Chair of the AAN Neuroimaging Section, agrees. “Often, there is a viable recourse, so it is wise to seek action.” When AAN members began to express frustration that they were performing specialized Transcranial Doppler studies but were unable to get paid, Dr. Tegeler worked with MEM to develop the proposals for new codes and present them to PEAC and RUC.

“Many administrators saw the procedures, which required specialized supplies, as a money-losing proposition,” Dr. Tegeler explained. “As a result, patients were being deprived of access to care.” He attributes the success of three new codes – “vasoreactivity study” (93890), “emboli detection without intravenous microbubble injection” (93892), and “emboli detection with intravenous microbubble injection” (93893) – to the dedicated efforts of AAN volunteers such as Marc R. Nuwer, MD, PhD, a CPT Advisor, Jim Anthony, MD, an RUC Advisor, Baldwin Smith, MD, an RUC member, and Laura B. Powers, MD, an ICD-9 Advisor, who sit at frequent meetings and work tirelessly for hours on end to represent the needs of neurologists. “It is clear that they are well-respected, they have the ears of the committee members, and they are doing a marvelous job representing us.”


“Establishing a new CPT code is a several step process,” explained Dr. Nuwer, Past Chair of MEM. ''First, because it takes an estimated one million dollars to create and implement a new code, we need to weigh its value versus cost; there needs to be enough of the service, such as, for example, 10,000 procedures per year nationally.

“Second, there should be no easy way to code it by using the existing CPT codes. Finally, services considered covered by existing E&M codes usually cannot be unbundled.”

Dr. Nuwer noted that there were plenty of DBS procedures performed annually, for example, but the question was whether the existing code adequately described the service. ''We argued that it did not, because it lumped DBS programming together with programming for spinal and peripheral stimulators – and the latter was substantially less work. After more than 60 users completed time and expense surveys, we reviewed the proposal with other societies and key contact people.

“Because every new procedure draws reimbursement away from the rest of the budget-neutral Medicare system,” continued Dr. Nuwer, “more money to a new procedure means less for every other procedure. We needed to develop allies to help us convince others of our needs. Finally, we presented to the CPT Editorial Panel, a group of 20 judges who represent various specialties and carriers.”


At times, members report reimbursement problems that require innovative strategies. For many years, there was a major ambiguity in the nerve conduction study code definitions – how to code for studies of two or more branches of a given motor or sensory nerve. MEM members, working in collaboration with the American Association of Electrodiagnostic Medicine, and with the approval of the AMA and HCFA, solved this problem.

“In the past, the method of determining which nerve conduction studies qualified as separate units was hopelessly complex,” said Neil A. Busis MD, a MEM member. “We proposed a much simpler solution to HCFA – namely a list of motor and sensory nerves that qualify as separate units of motor or sensory nerve conduction studies. To our delight, they agreed. We developed the list in 2001 and the AMA has published several revisions. The most up-to-date list, which all our members should use, appeared in the April 2003 issue of the AMA's CPT Assistant (Volume 13, Issue 4). The list is also available from the AAN.”

The AAN also gets involved when neurologists are denied reimbursement due to diagnostic coding problems. John Hart, Jr., MD, Associate Director for Clinical Activities at the Geriatric Research Education and Clinical Center of the Central Arkansas Veterans Healthcare System in North Little Rock, AR, and President-Elect of the AAN Behavioral Neurology Section, said: ''It became evident several years ago that the codes to describe dementia had not kept up with the level of knowledge and expertise that had evolved over the years and failed to accommodate the subtypes that had been identified, such as frontotemporal dementia and dementia with Lewy bodies. Consequently, neurologists were being forced to replace these entities with less specific codes.

“The consequences of failing to provide the federal government and other agencies with condition-specific codes can be that resources are not allocated to study these diseases or to provide researchers with funds or to help affected patients with treatments and other essential services,” Dr. Hart said. He consulted with MEM Chair Dr. Powers, who has advocated for new diagnostic codes and clarifications and improvements to the current codes for the past 12 years.


Carmela L. Tardo, MD, member of the Executive Committee of the Neurology Section of the American Academy of Pediatrics (AAP) and neurology liaison to the AAP Coding Committee, observed this tedious process. “I can't emphasize enough the fact that Dr. Powers has gone to ICD-9 meetings for years and sits through both procedural and diagnostic days, and this has accorded her and the AAN enormous respect,” she said. “The other members listen to her, solicit her comments, and routinely e-mail her for comments when receiving requests for code changes even remotely connected to neurology. In contrast, presenters from other societies often come in for an hour and leave. It is precisely because she has slugged through this stuff twice a year, year after year, that the AAN has been so successful.”

Dr. Powers attributed much of the success of MEM to Nelson G. Richards, MD. “Dr. Richards was the first to single-handedly choose neurology-specific codes from the full ICD-9-CM when it became mandatory for us to use these codes for office billing, and subsequently, he was the first to edit ICD-9-CM for Neurologists. He championed the practicing neurologist, from reimbursement to scope of practice to legislative issues. He represented us at AMA, was responsible for our initial presence at CPT, and started MEM.”

Requests for help come from AAN sections, groups, and individual members, as well as office managers and staff when they encounter coding and billing problems. “Their questions are often great starting points,” said Dr. Powers. “I usually research the codes myself and then find someone from AAN who is an expert to help me. The proposal then goes to the National Center for Health Statistics and, if accepted, is presented at the ICD-9-CM Coordination and Maintenance meeting in Baltimore at CMS.”

Dr. Tardo summed up: “Just being there, as Dr. Powers is with the ICD and Dr. Nuwer is with the CPT meetings, gets a lot accomplished; the process of code change, while simple in theory, requires a grasp of somewhat arcane terminology and conventions, as well as a certain amount of handshaking and politics.”