Diagnostic Nerve Ultrasound at Clinic Visit (Pain Practice)

[drg123]

I am a graduating pain fellow, PM&R background, and will be starting my first academic pain management job specializing in neuropathic pain. I would like to perform diagnostic nerve ultrasounds at the time of my initial or follow up E/M visits to evaluate and confirm diagnoses. I did a good amount in residency, mostly for median and ulnar neuropathy and some lower extremity.

There is a CPT code now for diagnostic nerve ultrasound (76883): CPT® Code 76883 - Diagnostic Ultrasound Procedures of the Extremities - Codify by AAPC. wRVU is 1.2 per extremity evaluated. Needs a separate note and images.

We usually did these scans in the context of an EDX visit, not during clinic E/M.

I'm wondering if anyone does this and if you're getting reimbursed. Do these scans need prior auth or can one just do them point-of-care without prior auth if deemed necessary?

Compared to the pain procedures I do, these are less RVU-dense, but if I do say 2 extremities (1.2 x 2 extremities, e.g. b/l tibial and peroneal and sciatic for distal polyneuropathy), that's not nothing. It would add up over time and I think it would add a lot of value to my assessment. For example, for diabetic polyneuropathy, there is robust literature showing enlargement of the tibial nerve with some normative values.

https://www.sciencedirect.com/science/article/pii/S2467981X23000136

If my goal is to do SCS or PNS long term for these patients, I think having definitive diagnosis of DPN would support approval for these procedures, and also perhaps in the future, having something objective to track in addition to pain to show effect of therapy. Like this paper interestingly showed changes in nerve CSA after SCS: Fast-Acting Sub-perception Spinal Cord Stimulation for a Case of Painful Diabetic Polyneuropathy. Just an Antalgic Treatment or Even a Therapy? - PubMed

So my questions are:
1. Can I do this linked to an E/M visit or does it need to be separate procedure visit?
2. Am I understanding correctly that it would be 1.2 wRVU per extremity, such that I could bill 2x for two limbs?
3. Is prior auth needed?
4. Are you getting paid?
5. Is this worth my time?
6. How long do these scans take you (scan + documentation) if you're doing them?

Thanks!

---

Members don't see this ad.

 

[JBM16BYU]

In my experience (neuromuscular PM&R who performs NMUS on a regular basis), nerve ultrasound is helpful for mononeuropathies and demyelinating Polyneuropathies, however, there is not sufficient evidence for its use in axonal polyneuropathy (I.e. diabetic PN). It is best used in combination with EDX. Perceived enlargement of a single nerve (like tibial) from reference values is not enough to diagnose an axonal polyneuropathy, not without EDX to back up the diagnosis. There are plenty of reasons for a nerve to become enlarged, some of which are pathological but some are physiological and within upper limits of reference ranges.y recommendation would be that if you want to incorporate nerve ultrasound, it be done in conjunction with EDX in that same visit or on a patient who already had EDX performed. Again, the utility in axonal PN is not shown currently.

NMUS can show potential etiology and enlargement of nerves, but severity is determined via EDX.

If you are performing NMUS with that new code, several images plus a video of the length of the nerve is required for reimbursement. Plan for at least 10 minutes, depending on the nerve, but sometimes you will need more if you want side to side comparison.

 

[drg123]

In my experience (neuromuscular PM&R who performs NMUS on a regular basis), nerve ultrasound is helpful for mononeuropathies and demyelinating Polyneuropathies, however, there is not sufficient evidence for its use in axonal polyneuropathy (I.e. diabetic PN). It is best used in combination with EDX. Perceived enlargement of a single nerve (like tibial) from reference values is not enough to diagnose an axonal polyneuropathy, not without EDX to back up the diagnosis. There are plenty of reasons for a nerve to become enlarged, some of which are pathological but some are physiological and within upper limits of reference ranges.y recommendation would be that if you want to incorporate nerve ultrasound, it be done in conjunction with EDX in that same visit or on a patient who already had EDX performed. Again, the utility in axonal PN is not shown currently.

NMUS can show potential etiology and enlargement of nerves, but severity is determined via EDX.

If you are performing NMUS with that new code, several images plus a video of the length of the nerve is required for reimbursement. Plan for at least 10 minutes, depending on the nerve, but sometimes you will need more if you want side to side comparison.

Thanks for your insights. I should have said, I'd definitely like to apply NMUS to the common mononeuropathies where this technique is readily applied (CTS, UNE), but was hoping to expand application to some common polyneuropathies that I will likely see, especially DPN. Based on your feedback, perhaps that time is not yet or in conjunction with EDX.