Neurology billing is challenging, especially for electrodiagnostic procedures, due to their complex nature and specific billing requirements. A particularly challenging electrodiagnostic code that many billers get wrong is CPT code 95886. So, how can you bill it correctly?
Well, that is what this blog is all about. In this guide, we will discuss in detail what CPT code 95886 is, its correct application, and billing requirements. So, let’s start.
CPT Code 95886 – Description
The Current Procedural Terminology (CPT) code 95886 is officially defined as:
“Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude, and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).”
Sounds confusing? Let’s try to break this down in simpler terms.
Firstly, 95886 describes a needle electromyography (EMG) procedure. In this procedure, the physician inserts fine needle-like electrodes into the muscles to record their electrical activity. This is done both at rest and during muscle contraction. The whole purpose of this test is to evaluate the muscle and nerve function (peripheral nervous system).
The definition also mentions “each extremity”. Extremity here means an arm or a leg and can include related paraspinal areas (muscles along the spine) if examined during the same session.
Furthermore, code 95886 represents a complete EMG study of the extremity. This is defined quantitatively: the study must involve testing five or more muscles within that extremity (and any related paraspinal muscles tested). Three or more distinct nerves must innervate these muscles or correspond to four or more spinal levels.
Another important thing that many billers miss is that CPT code 95886 is an add-on code. This means that it cannot be used for billing alone and must always be accompanied by a primary service code, e.g., nerve conduction studies (NCS) codes 95900-95904. So, in most cases, you will have to put a “+” sign with it in your claim.
Another rule for using CPT code 95886 is the “same-day requirement.” According to this rule, the EMG study must be performed on the same day as nerve conduction studies to use this code.
Scenarios Where CPT Code 95886 is Applicable
To better understand how to use CPT code 95886 practically, let’s look at some real-world scenarios in which this code can be used:
Diagnosing Cervical Radiculopathy
Suppose a 50-year-old patient arrives at the clinic with a stabbing pain that radiates from his neck to his arm. He also feels numbness and tingling sensations in the entire arm. These symptoms suggest that there might be pressure or irritation on the nerve roots in the cervical spine (neck), a condition known as cervical radiculopathy. However, to accurately diagnose and assess the extent of nerve compression, the physician orders a complete EMG.
At the end, the medical billing department codes and submits the claim for reimbursement. In this case, CPT code 95866 is used along with a relevant conduction study primary code.
Evaluation of Peripheral Neuropathy
Suppose a patient with diabetes comes to a neurologist. He complains of tingling and weakness in the feet. This suggests a potential peripheral neuropathy. To evaluate the extent and nature of nerve damage, the physician orders a thorough EMG study. This test will assess the electrical activity of the muscles in the patient’s feet and legs.
After the EMG study is performed, the medical billing department codes and submits the claim for reimbursement. Similar to our previous scenario, the billing department will use CPT code 95886 to bill the EMG with a primary NCS code.
Applicable Modifiers for CPT Code 95886
You may append the following modifiers to CPT 95886 (when needed) for coding specificity and accurate reimbursement collection.
Modifier 52
The modifier 52 is assigned to indicate reduced services. For example, if a complete EMG study is planned but fewer than five muscles are studied due to patient factors, then modifier 52 can be used.
Modifier 59
Modifier 59 represents a distinct procedural service. So, if other services were performed on the same day as needle electromyography, you will use modifier 59 with CPT code 95886 to indicate that it is a distinct service and separately billable. This modifier helps you avoid claim duplication denials.
Modifiers 26 and TC
CPT code 95886 is assigned a PC/TC indicator value of 1 by the Centers for Medicare and Medicaid Services (CMS). This means that if the practices perform the procedure, they should bill it using the modifier TC, which represents the technical part of the procedure. But if the physician only interprets the test results, then only the professional component of the procedure should be billed with modifier 26.
CPT Code 95886 – Billing & Reimbursement Guidelines
The following billing and reimbursement guidelines will help you file clean claims for your needle electromyography procedure.
Provide Detailed Documentation
Documentation is the key to successful billing. The medical records must justify the need for the procedure and the depth of the procedure. Essential details to mention for billing 95886 are:
- Presence/absence of spontaneous activity
- Characteristics of motor unit potentials
- Recruitment patterns
- Interpretation of findings
Follow Unit Reporting Guidelines
CPT code 95886 is reported per extremity examined:
- One unit for each extremity (arm or leg) that receives a complete EMG study
- Maximum of four units per patient per encounter (representing all four extremities)
- When testing multiple extremities, each should be reported as a separate unit
Reimbursement Rates
The reimbursement amount of 95886 varies based on the Medicare Administrative Contractor (MAC) facility and locality. However, Medicare’s national average reimbursement rate for CPT code 95886 in facility settings is:
- Professional Component: $43.02
- Technical Component: $47.55
Wrapping Up
CPT code 95886 is an essential neurology billing code. However, billing for it can be tricky. For successful reimbursement, keep an eye on the documentation, appropriate modifiers, and the number of billing units. By following the suggestions provided in this guide, healthcare providers can get fair reimbursement for their services.
If you are facing claim denials even after following all the guidelines in this blog, consider getting our neurology billing services. Our billing experts have decades of experience in handling all kinds of billing issues and denials.
