One of the biggest issues facing SIU's today is the rise in diagnostic studies being performed and billed by providers. Typically, diagnostic tests such as nerve conduction velocity (NCV) studies are performed by physicians in the neurological or physical medicine and rehab specialties. They are used to evaluate the nerve and muscle function for neuromuscular disease and to aid in diagnosing conditions including carpal tunnel syndrome, chronic inflammatory polyneuropathy and neuropathy, peripheral nerve injury, and other conditions affecting the nervous system. [1]
In the past few years, insurance payers have seen an increase in the claims submitted for these services by providers in the pain management, family practice, and internal medicine specialties. As technology has advanced, it has become easier than ever for smaller practices to purchase machines that perform these tests. The problem is, providers are potentially performing these diagnostic tests on patients that may not be medically necessary. Additionally, the equipment used may also not meet required guidelines.
Many insurance payers have medical policy guidelines for nerve conduction studies that clearly indicate what is considered to be medically necessary for a patient to have the NCV tests eligible for payment. These indications almost always include some kind of muscle or nerve disorder be present. [2]
Additionally, most payers exclude coverage for machines that are automated. [3] These automated devices are marketed to physicians as a way to bill for NCV testing and to generate additional revenue for the practice. They are non-invasive and typically have touch-screen interfaces that allow the services to be performed by non-physicians and only require minimal training. They typically involve placing electrodes on various parts of the body and then telling the system which programs to run. At the conclusion of the tests, a printout is provided to reflect the results. These are actually considered neural scans and are not truly NCV tests. [4, 5] However, more and more providers are billing for these non-covered services using improper CPT codes and are receiving payment in error.
What should investigators look for?
Investigators should be on the lookout for codes 95907 - 95913 being billed in excessive amounts, specifically within the specialties of Pain Management, Family Practice, and Internal Medicine. Using peer-analysis analytics such as PostShield™ can also help investigators find providers within these specialties that bill for these services in excess of their peers.
Other red flags may include seeing these same codes billed without a related EMG test (95860 - 95887) performed either concurrently, or within a reasonable period of time prior to the NCV tests. Certain payers require the test to be performed at the same time, others allow up to a year prior and some payers do not have clearly defined policies at all. Investigators should be sure to check your company's policies in addition to any relevant state or federal guidelines to ensure they are compliant.
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