Internal medicine now performs more NCSs than PMR

Discussion in 'MSK and EMG Case Discussions' started by Ludicolo, Apr 29, 2008.

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  1. Ludicolo

    Ludicolo Fib Hunter 7+ Year Member

    Interesting tidbit from the April 2008 AANEM newsletter:

    “Internal Medicine Now Performs More NCSs Than PMR

    According to Medicare claims data from 2006, internal medicine (IM) physicians billed for over 50,000 more motor nerve conductions studies with F wave (CPT 95903) than physical medicine and rehabilitation physicians (PMR). This data demonstrates that for 95903 claims, IM physicians have bumped PMR as one of the top two specialties billing for 95903, with PMR falling behind IM and general practice physicians. Historically, neurology and PMR physicians have been the top two specialties submitting claims for 95903. Over the last 5 years there has been a significant increase in billing among IM, general practice, and family practice physicians…. IM physicians have increased 95903 claims submissions to Medicare from 2002-2006 by 569%, with general practice and family practice at 290% and 469% respectively. Usage of automated nerve conduction testing devices may be contributing to this increase. The AANEM continues to work to ensure that patients receive quality electrodiagnostic care by educating payors via the State Liason Program, and by working with the American Medical Association CPT editorial panel to clarify billing for NCSs.”

    There is a graph accompanying the article, which I cannot download, that shows the # of claims for this code for PMR physicians from 2002 to 2006 went from 128,305 ito 182,904 (43% increase). For neurologists: 565,284 to 840,906 (49% increase). For IM docs: 34,927 to 233,647 (569% increase).
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  3. topwise

    topwise 5+ Year Member

    Sep 6, 2007
    What are automated nerve conduction testing devices??
  4. Ludicolo

    Ludicolo Fib Hunter 7+ Year Member

    Google "NC-Stat" or "Brevio" for more details.

    Briefly, these are hand-held devices designed for point-of-care treatment (i.e. primary care) which after electrode placement, generate waveform data. Then the device is docked and the data transmitted to a central database, which then generates an automated report, usually within minutes. Benefits are ease of use and quick results. The needle EMG is not performed.
  5. Nikiforos

    Nikiforos Junior Member 7+ Year Member

    Oct 29, 2003
    The problem is not only that internists and family practitioners are now doing these electrodiagnostic studies, but also that physiatrists and neurologists are abusing the privilege. There is no justification for the huge increase in utilization over 4 years except for the fact that these studies are moneymakers. Despite the name, electrodiagnostic studies are by themselves not "diagnostic." It's a matter of time before reimbursements for these studies are decreased to the point that they are no longer more profitable on a per unit basis than simply seeing a followup or a new eval.
  6. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor 5+ Year Member

    Oct 1, 2007
    Already Medicare has begun asking for further documentation on some of my more complicated cases that fall outside the 90% rule as recommended by AANEM and now apparently adopted by Medicare. If I've had a patient with more than 4 units of motor or 6 units of sensory, it gets denied with request for documentation.

    The tides are definately ebbing. What was once quite profitable is falling, as expected. In our capitalist society, too many medical product companies are wooing GP's into buying machines for no other reason than to increase bottom line.

    I see these NC-Stat reports all the time. Most are poorly done and poorly interpreted by a computer algorithm.

    Join AANEM!! Protect your future!!
  7. Ludicolo

    Ludicolo Fib Hunter 7+ Year Member

    Agreed. These companies pander directly to the GPs, most of whom have no in depth training in neuromuscular medicine, and as part of their sales pitch instruct the GP on which CPT codes to use for their machine, so as to maximize their bottom line. But these CPT codes were meant for standard NCSs, performed in real-time. They leave out that they should be using an associated HCPCS code S3905 (EDX testing with automatic hand-held devices) - Most insurances, including Medicare, will not cover this.

    Nikiforos - No doubt there are unscrupulous neurologists and physiatrists as well. But considering that the absolute number of board certified neurologists and physiatrists performing NCSs have increased since 2002, and that the general patient population has also increased, you would expect a rise in the # of claims across the board. The % increase is similar for neuro and PM&R. You would think there would be a similar % increase for IM. But >500%?

    One point to consider is that PM&R is the ONLY specialty where NCS/EMG is a required part of residency training. Residents are required to demonstrate competency (i.e. 200 EMGs) prior to graduation. This should be a topic close to our hearts. Not only should we protect our future, we should be protecting our patients who undergo unnecessary and sub-optimal testing.
  8. Nikiforos

    Nikiforos Junior Member 7+ Year Member

    Oct 29, 2003
    Ludicolo, it seems unreasonable to think that the increase in the number of physiatrists and neurologists between 2002 and 2006 accounts for the very large increase in the numbers of EMGs done in that time frame. It is also hard to believe that the population increase accounts for this.

    A more plausible explanation (and one that laypeople understand very well) is that doctors see EMGs as a way to make more money on a per unit basis of time. As we have been taught (and know), EMGs are not diagnostic. They are merely an extension of the physical exam. For example, a significant number of electrodiagnostic studies for carpal tunnel syndrome fall into either the false positive or false negative categories.

    Doctors influence their income (upward) in many creative ways. Electrodiagnostic studies are one of these ways. Spinal injections are another procedural category ripe for abuse. Are all these studies and procedures justified? Definitely not. The best way that Medicare, insurance companies, and HMO's can curb the overutilization (and accompanying financial abuse of our health care system) is by cutting reimbursements for EMGs (and spinal injections) to a level that will make them financially unattractive to do.

    Within the last 5-10 years, there was a Yale residency trained neurologist in a northeastern state that was convicted and sent to federal prison for billing for electrodiagostic studies that he either had not done or had not done at the level he billed for. He was caught in an FBI sting with undercover agents posing as patients.
  9. SSdoc33

    SSdoc33 10+ Year Member

    Apr 23, 2007
    I wasnt aware that providing objective evidence of a nerve injury, ALS, or a treatable myopathy was "creative way to supplement income". i thought that it was proven, legitimate, and useful medical practice.

    And no, the BEST way that HMOs can curb overutilization is to cut down on bogus and unnecessary studies, not to decrease the reimbursement. to actually review the studies that are done, and not to not pay for chiros billing 4 limb EMGs or GPs and their ridiculous NCS. of course, that would actually require more work and a knowledge of what is a good study and what is BS. that costs $$$. much easier to just cut payment. doesnt really matter whats best for the patients......

    and yeah, docs want to make money. something wrong with that? as long as its done legitimately, whats the problem? nobody is defending the crooks who bleed the system, we just get pissed when insurance companies decide whats best for patient care.
  10. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor 5+ Year Member

    Oct 1, 2007
  11. Ludicolo

    Ludicolo Fib Hunter 7+ Year Member

    Nikiforos - As I said before, I will whole-heartedly agree with you that there are some immoral neurologists and physiatrists who have no business performing NCS/EMGs. And if they were “properly trained” in EDX medicine then I think that speaks to the individual, rather than the specialties as a whole. For the sake of argument, let’s say that this overall % increase is significantly due to unnecessary testing/improper utilization of resources. Still – the percentage increase for neuro and rehab are similar. Since the percentage increase in NCSs performed by IM docs is on a magnitude of 10x greater than either neuro or rehab, does that imply the IM specialty has a greater number or percentage of immoral physicians?

    Yes, the temptation to increase the bottom line is always there, but most electrodiagnostic physicians, (or pain specialists – since you brought up spinal injections), should have been comprehensively taught what performing these procedures fully encompasses – including the moral, ethical and medicolegal implications. My point is that as a rule, IM and FP docs performing these NCS or spinal procedures have not. Is this a reason why these companies directly market to these primary care specialties, because they don’t know any better? Don’t know.

    And as for your comments regarding that “as we have been taught (and know), EMGs are not diagnostic”. I will say that it appears that you and I have been instructed differently in this regard. Perhaps we should come to an agreement on what a “diagnostic test” represents.

    PS - :thumbup: to SSdoc33 as well.
  12. neglect

    neglect 1K Member 10+ Year Member

    Sep 2, 2003
    There are gray zones within the word "legitimately" here. Like what do you want to do with a young woman who wakes up with numb hands? Go right to the NCV so we can diagnose mild or no median neuropathy? I've seen it done. Or getting NCVs on run of the mill peripheral neuropathies. Or the psych/fibromyalgia cases?

    I've seen senior guys, who don't really need the money clinically and perhaps don't really care that much if they miss something, only do one sensory nerve and one motor nerve and two rep stims for myasthenia and a few muscles. So it isn't only who you do it on, but how much you do.

    Overuse of procedures is occuring throughout medicine and the reasons are multifactorial. I think a big one is the growing delta between the well off and the very well off. Another is how little the intellectual work of medicine pays, and how difficult it is. Another is the very real sense that everyone else is doing it. Another is the growing sense among patients that this is what they need, that more is better.

    I'm resisting, personally. I tell the young girl to brace her hands and come back in follow up (never see her again), and don't do neuropathy ncvs without thinking demyelinating. But then again, how long can I keep resisting? How long can any of us? Last year one of my patients told me, proudly, that he partied his way through college and now sells things (and acts as a QC, manages things on the manufacturing end, and works at least 12 hour days) and makes ten percent of his 3 million in sales per year.

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