Article - Billing and Coding: Somatosensory Testing (A57597)

CMS National Coverage PolicyItalicized fontrepresents CMS national language/wording copied directly from CMS Manuals or CMS transmittals. Contractors are prohibited from changing national language.Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessaryinformation to process the claim.Code of Federal Regulations:42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).CMS Publications:CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Publication 100-03, Medicare Benefit Policy Manual, Chapter 1, Part 2: Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)CMS Publication 100-04, Medicare Benefit Policy Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements: Section 10 - Reporting ICD Diagnosis and Procedure CodesArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.Utilization GuidelinesIt 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 thatreasonable 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; andthe 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 RequirementsThe 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 patients course of treatment. In addition, documentation that the service was performed must be included in the patients medical record. This documentation should include a hard copy computer generated recording of the test results along with the providers interpretation. The providers 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 practitioners 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.