NCS/EMG consultation fee

[bedrock]

I'm a recent fellowship grad just starting the EMG part of my private practice. I did my EMG training with both neurologists and physiatrists. My PM&R attendings took a history and did a neurological exam as a part of every patient EMG(and documented it), the neurology attendings just did the NCS/EMG preceded by an extremely brief "where does it hurt" query.

My main question to the forum is- Can you bill a consultation fee in addition to the NCS/EMG fee? If so, do you modify your NCS/EMG coding in some way? I never witnessed things coded this way in academics, but coding is rarely a focus of post-graduate training unfortunately.

I would think a level 3 consult would be appropriate given the time spent doing this "PM&R" style where the EMG is an extension of your history and examination.

I also wanted to ask if people had recommendations for setting up the new EMG portion of my practice. (pitfalls to avoid) I'm working with a surgical group which will be sending 80% of my EMG referrals, but I'll also be getting some primary care EMG referrals as well.

I expect to do EMGs much more efficiently than during residency/fellowship because I'll have 2 rooms, someone to room patients for me, and disposable electrodes, but I'm debating how much time to allot for studies until I see what my partners start sending over. I do plan to educate the surgeons and PCPs I work with so they can be somewhat specific requesting EMGs so patients can be booked for an appropriate amount of time. (In academics, everyone got booked for the same amount of time whether it was unilateral CTS or bilateral brachial plexopathy.

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[PMR 4 MSK]

Excellent questions.

You can bill a consult, if a consult was requested (preferably in writing), you do the H&P, document it with assessment and plan or recommendations. However, Medicare is doing away with consult codes next month in favor of new pt codes, and other insurances are likely to follow. You can just bill a new pt code, if you did more than the EMG - such as prescribing meds, PT, did a separate injection, prescribed braces, etc, and you document the H&P, A&P. Most of the time, E&M is not really justified, unless you are taking an active part in the patient's treatment plan - i.e. doing more than being the tester. Some people do more H&P than others, not likely decided by PM&R vs Neuro. For most of my pts, the H&P is brief, but most of my referrals are "R/O CTS."

For about 7-8 years, I did 1 hour/EMG. Now I schedule 1/2 hour/limb, but sometimes don't get my reports done before the next pt and have to do them later. It's worse when I get something that requires more testing than the referred single limb. I try not to schedule EMGs after clinic pts, because I don't like them waiting for the test when I run behind.

Educate your schedulers the most for it - you may have to look at each referral for a while and help them decide how much time to allot. But you never know when a complicated one will blow your whole day.

 

[drusso]

You also need to consider the reason why the patient was sent to you. If it's "R/O CTS," then you have two choices:

a) You could just do the EDX +/- brief exam and charge only for the EDX component

b) You could respond to the "R/O CTS" by outlining a comprehensive conservative tx plan in addition to the EDX and charge for both consult and EDX.

 

[Disciple]

Without some kind of pre-cert for both, I'd be worried that the insurer might choose to pay for the E&M service and deny payment for the EMG.

 

[axm397]

I do 45 minute slots for EMG/NCS regardless of one limb vs two. I also tell the schedulers to try to schedule one limb for earlier and bilateral for the later slots so I don't run behind. I bill a level 3-4 for most because I end up prescribing meds, ordering labs, giving out splints, and/or ordering imaging. If it's just r/o CTS, I usually don't - and just do the EMG - but some times I end up diagnosing periph neuropathy or cervical radic - then I order neuropathy labs or c spine MRI - and i do bill for the visit.

I think when u r starting out, u should do the whole study yourself. A lot of patients go back to the PCP and talk about their experience. I have had patients tell me that they were impressed that I actually did the H&P and NCS and EMG myself because they or their family members have had EMG/NCS done by techs (or the doc just came in for the EMG part and didn't even talk to them). I like taking the time during the study to chat and talk about THEM - which makes them feel listened to and happy --> then they go back to the referring docs and tell them how satisfied they were with the care they received. I also go over the results with the patients at the end. I defer surgical questions to the surgeons themselves.

I schedule all EMGs in designated 1/2 day clinics. It's tough to juggle "regular" clinic patients and do EMGs in between. If I run late (i.e. r/o CTS turns into r/o neuropathy or worse) I make sure to inform the next patient how much I'm running behind by - and give them the option to reschedule if they don't want to wait.

 

[Ludicolo]

Good advice here so far.

My main question to the forum is- Can you bill a consultation fee in addition to the NCS/EMG fee? If so, do you modify your NCS/EMG coding in some way? I never witnessed things coded this way in academics, but coding is rarely a focus of post-graduate training unfortunately.

Yes you can. If you do an EMG + E/M visit (consult/NV/follow up) on the same day and make further diagnostic/treatment recs based on your H&P and/or EMG results, attach a 25 modifier to your E/M code. It helps though if the referring physician documents a request for a PM&R consult, and not just a request for an EMG. Sometimes, I'll call the referring physician to clarify exactly what they want, or to suggest that the patient may benefit from PM&R services in addition to the EMG. Document carefully.

I also wanted to ask if people had recommendations for setting up the new EMG portion of my practice. (pitfalls to avoid) I'm working with a surgical group which will be sending 80% of my EMG referrals, but I'll also be getting some primary care EMG referrals as well.

I expect to do EMGs much more efficiently than during residency/fellowship because I'll have 2 rooms, someone to room patients for me, and disposable electrodes, but I'm debating how much time to allot for studies until I see what my partners start sending over. I do plan to educate the surgeons and PCPs I work with so they can be somewhat specific requesting EMGs so patients can be booked for an appropriate amount of time. (In academics, everyone got booked for the same amount of time whether it was unilateral CTS or bilateral brachial plexopathy.

I also tend to have half-days dedicated to EMG patients. I budget 60 min per EMG regardless of the indication for study, mostly because I’m working w/ residents/fellows and I need the extra time for teaching. Since you’re starting out, I would perhaps book a little extra time for EMGs during the first 3-6 months until you get a better sense of your practice flow and referral patterns.

To touch on something that axm mentioned, I’ll review EMG results with the patient immediately afterwards if I’m managing any part of the patient’s care. If I just did an “EMG only” – I’ll let the referring physician go over the results.

 

[RUOkie]

Without some kind of pre-cert for both, I'd be worried that the insurer might choose to pay for the E&M service and deny payment for the EMG.

That is always a valid concern. In general I only do a separate consult if specifically requested by the referring doc. The flip side (and this is NOT what AANEM wants us to do) is that if they do not ask for the consult, then I do not provide treatment advice (ie if there is a multifocal neuropathy, I just mention it and don't give recommendations for workup). I will usually call the referral source in those situations.

I also state on each report (this is built into my report generator)
The nerve conduction studies and EMG of this examination was performed by the physician without the use of a technician.

The neurologist in my town (my only competitor) has now fired his technician because he was losing to much business. Docs like that docs do the test.

The best advice I can give is "don't be greedy". Take more time initially and do the best job possible. Then, change your schedule as you see fit. EMG/NCS is what pays the bills, so cultivate that part of your practice, and you will have lots of time to do other things.

 

[PMR 4 MSK]

That is always a valid concern. In general I only do a separate consult if specifically requested by the referring doc. The flip side (and this is NOT what AANEM wants us to do) is that if they do not ask for the consult, then I do not provide treatment advice (ie if there is a multifocal neuropathy, I just mention it and don't give recommendations for workup). I will usually call the referral source in those situations.

I also state on each report (this is built into my report generator)
The nerve conduction studies and EMG of this examination was performed by the physician without the use of a technician.

The neurologist in my town (my only competitor) has now fired his technician because he was losing to much business. Docs like that docs do the test.

The best advice I can give is "don't be greedy". Take more time initially and do the best job possible. Then, change your schedule as you see fit. EMG/NCS is what pays the bills, so cultivate that part of your practice, and you will have lots of time to do other things.

I think I'll incorporate that phrase into my reports as well.

As for E&M, remember H&P are considered integral to an EMG and is not paid separately, no matter how involved. However, if you do come up with a separate treatment plan for the pt, I think it is reasonable to bill E&M c/w amount of time and documentation to support it.