Billing and Coding: Somatosensory Testing

The billing and coding information in this article is dependent on the
coverage indications, limitations and/or medical necessity described in the
related LCD.

**Utilization Guidelines**  
It is expected that these services would be performed as indicated by current
medical literature and/or standards of practice. When services are performed
in excess of established parameters, they may be subject to review for medical
necessity.

The Medicare Physician Fee Schedule Database (MPFSDB) physician supervision
indicator for CPT codes 95925, 92526, 95927 and 95938 have Level 21 for the
technical component. Level 21 defined as: _Procedure may be performed by a
technician with certification under general supervision of a physician.
Otherwise the procedure must be performed under direct supervision of a
physician. Procedure may also be performed by a PT with ABPTS certification
without physician supervision_.

Program Memorandum Transmittal B-01-28/Change Request 850 sets forth revised
levels of physician supervision required for diagnostic tests payable under
the Medicare Physician Fee Schedule. Effective July 1, 2001, certain codes in
the range of CPT 95860-95937 were assigned new supervision levels (21, 22, 6a,
66, 77 or 77a). This implementation date would make it possible for physical
therapists to acquire the certification required to perform these services
without supervision. A physical therapist who is presently certified by the
American Board of Physical Therapy Specialties can perform procedures assigned
level of 21, 22, 66, 6a, 77, or 77a without supervision. These numeric levels
assigned to the CPT codes are listed in the Medicare Physician Fee Schedule
Database (MFSDB). _Physical therapists who do not possess the ABPTS (American
Board of Physical Therapy Specialties) certification by July 1, 2001, may
continue to furnish those tests that require the certification if they have
been furnishing such diagnostic tests prior to May 1, 2001_.

Therefore, if authorized by state law Physical Therapists are allowed the
technical portion of the test.

_Nurse practitioners, clinical nurse specialists, and physician assistants are
not defined as physicians under 1861(r) of the Act. Therefore, they may not
function as supervisory physicians under the diagnostic tests benefit
(1861(s)(3) of the Act). However, when these practitioners personally perform
diagnostic tests as provided under 1861(s)(2)(K) of the Act, 1861(s)(3) does
not apply and they may perform diagnostic tests pursuant to State scope of
practice laws and under the applicable State requirements for physician
supervision or collaboration. (_CMS Publication 100-02 _, Medicare Benefit
Policy Manual_ , Chapter 15: Section 80: Requirements for Diagnostic X-Ray,
Diagnostic Laboratory, and Other Diagnostic Tests).

CMS Publication 100-08, _Program Integrity Manual_ , Chapter 13, Section 5.4
outlines that _" reasonable and necessary" services are "ordered and/or
furnished by qualified personnel."_ Provision of interpretation and/or
supervision of these tests will be considered medically reasonable and
necessary only if performed by appropriately trained providers. Training and
expertise must have been acquired within the framework of an accredited
residency and/or fellowship program in the applicable specialty/subspecialty,
certification by a nationally recognized organization, or by an accredited
post-graduate training course covering anatomy, neurophysiology and forms of
electrodiagnostics (including both NCS and EMG). If this skill has been
acquired as continuing medical education, the courses must be comprehensive,
offered, sponsored, or endorsed by an academic institution in the United
States and/or by the applicable specialty/subspecialty society in the United
States, and designated by the American Medical Association (AMA) or the
American Osteopathic Association (AOA) as Category 1 Credit. Documentation of
training must be available upon request.

It is expected that the training and experience would include:

  * existing knowledge of the anatomic structures and neurophysiologic events underlying the generation of evoked potentials;
  * the influences of stimulus parameters and other experimental variables on the responses that are recorded;
  * relevant normative data and statistics; and
  * the clinical significance and pathologic correlates of dysfunctional neural pathways demonstrated by evoked potential alterations.

CMS long-standing policy that the concept of physician supervision does not
apply (PSI of "09") to these PT-designated diagnostic services, which allows
payment to be made for the PC or global code to the ABPTS-PT, excepted by
regulation, as long as it is legal for the ABPTS-PT to provide the service in
that state, and the TC has been either personally performed by the ABPTS-PT or
the PT without the ABPTS certification has met the supervision requirements
for the technical component portion of the service consistent with the
applicable supervision indicator.

**Documentations Requirements**  
The patient's medical record must contain documentation that fully supports
the medical necessity for services included within this Article and related
LCD. This documentation includes, but is not limited to, relevant medical
history, physical examination, and results of pertinent diagnostic tests or
procedures.

Medical record documentation maintained by the performing provider must
clearly indicate the medical necessity of the service being billed. There
should be evidence in the medical record that the test results were noted and
influenced or contributed to the patient's course of treatment. In addition,
documentation that the service was performed must be included in the patient's
medical record. This documentation should include a hard copy computer
generated recording of the test results along with the provider's
interpretation. The provider's SEP report should note which nerves were
tested, latencies at various testing points, and an evaluation of whether the
resulting values are normal or abnormal. This information is normally found in
the office/progress notes, hospital records, and/or procedure notes.

If the provider of somatosensory testing is other than the ordering or
referring physician or nonphysician practitioner, the provider of the service
must maintain a copy of the test results and interpretation, along with copies
of the ordering/referring physician/nonphysician practitioner's order for the
studies.

Providers of interpretations, supervision, and performance of the technical
portions of the studies must be capable of demonstrating documented training
and experience for post-payment audit.