Proper Coding of Nerve Block With EMG Guidance Requires Careful Review of OP Report
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Be careful when reviewing of the operative report documents that a nerve is being injected using electrical stimulation or EMG or when the superbill comes with "peripheral nerve block with EMG guidance" noted or checked off.
At first glance, it might appear as if another procedure was performed in addition to the nerve block. For electrical stimulation or EMG guidance, we might be tempted to look at CPT code 95873 — "electrical stimulation for guidance in conjunction with chemodenervation" or 95874 — "Needle EMG for guidance in conjunction with chemodenervation…".
There are two things to ask and/or look for when these procedures come across the desk. First: Was the injection truly a chemodenervation? CPT has a parenthetical note below 95874 telling us to report this and 95873 only in conjunction with 64612-64614, which is for the chemodenervation or destruction of various nerves. That means if the injection we're looking at is only meant to treat or block a nerve, these two codes shouldn't be used to report the procedure.
Second: Was the electrical stimulation or the EMG just used for guidance, or was there an actual study going on? Look to the operative report or other documentation to see if there's a formal report detailing the exact nerves studied and the findings somewhere close by. What could have happened is that the physician used electrical stimulation or electromyography to make sure the right spot was found for the injection to be effective in a similar way that fluoroscopy (77002/77003) is used to make sure the needle is in the right location.
Just like CPT 72275 for an epidurogram would be reported only when images are taken and there is a formal, written radiologic report (complete with findings, not just a detail of the contrast flow), electrical stimulation and EMG studies are diagnostic tests reported only when a formal report of the nerves studied and any assessment or findings is written. If the procedures are done to direct the physician to the most effective area for an injection other than for the destruction of a nerve, then it's not appropriate to use 95873 or 95874, nor is it appropriate to report other EMG/electrical stimulation CPT codes that are mentioned in other parenthetical notes.
What should be reported when EMG/electrical stimulation guidance is performed with a nerve block that isn't mentioned as being for chemodenervation or destruction?
Only the nerve block is coded when EMG/electrical stimulation is used for guidance purposes.
CPT Assistant from Feb. 2004 addresses the issue of electrical stimulation in their vignettes for various nerve blocks. In these procedures, the electrical stimulation is included with the CPT for the nerve block and isn't separately reported.
The NCCI Policy Manual for Medicare Services, Chapters 2 and 11 address these specific issues as follows:
Chapter 2: "Anesthesia HCPCS/CPT codes include all services integral to the anesthesia procedure such as preparation, monitoring, intra-operative care, and post-operative care until the patient is released by the anesthesia practitioner to the care of another physician. Examples of integral services include, but are not limited to, the following: …
- Nerve stimulation for determination of level of paralysis or localization of nerve(s). (Codes for EMG services are for diagnostic purposes for nerve dysfunction. To report these codes a complete diagnostic report must be present in the medical record.)
Chapter 11 differs a little from CPT in that nerve destruction is considered inclusive to the procedure(s): "Electrical stimulation used to identify or locate nerves during a procedure involving treatment of a cranial or peripheral nerve (e.g., nerve block, nerve destruction, neuroplasty, transection, excision, repair) is integral to the procedure and is not separately reportable."
When all is said and done, it remains critical that the report be dictated in a way that shows the procedures, how and where they are done and sometimes it's just as important to document the intent of the procedure so that the encounter can be accurately reported for the best reimbursement.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
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