The Office of the Inspector General (OIG) released its first evaluation on electrodiagnostic (EDX) testing earlier this week. And much of its analysis was based directly upon AANEM publications.
The study looked at Medicare payments made to physicians in 2011 for EDX tests and found that Medicare paid approximately $486 million to more than 21,000 physicians. OIG undertook this study because, “Recent investigations have found that electrodiagnostic testing is an area vulnerable to fraud, waste, and abuse.” What they found was that 4,901 physicians had “questionable billing” for EDX testing of Medicare patients, amounting to $139 million in charges. Fifty-one percent (51%) of those physicians practiced in areas other than neurology or physical medicine. Other specialties almost always billed for EDX tests without having both an NCT and a needle EMG test on the same claim representing approximately $72 million in payments.
The study developed seven measures of “questionable billing” based largely on AANEM publications. The seven measures included physicians who billed for an unusually high percentage of:
EDX test claims using modifier 59
EDX test claims using modifier 25
In 2011, 2208 physicians billed for an unusually high percentage of EDX tests using these modifiers, accounting for $47 million of the 2011 payments for EDX tests.
EDX test claims compared to other claims submitted (for providers other than neurologists or physiatrists) For example, 23 physicians billed only for EDX tests and no other Part B items and services in 2011, totaling $685,000.
EDX test claims that did not include both an NCT and a needle EMG (not including testing for carpal tunnel syndrome)
These claims accounted for $19 million of the 2011 payments for EDX tests. All these claims were by neurologists or PMR physicians. “None of the physicians in other specialties were identified statistically as having 'unusually high' billing because they almost always billed for electrodiagnostic tests without having both an NCT and a needle EMG test on the same claim; the median for such physicians was 85 percent. These physicians represented approximately $72 million in payments,” stated the OIG report.
Beneficiaries for whom at least three physicians billed Medicare for EDX testsThese claims accounted for $3 million of the 2011 payments for EDX tests.
The last two measures involved unusually high average number of:
Miles between the physicians’ and beneficiaries’ locations
These claims accounted for $15 million of the 2011 payments for EDX tests.
EDX test claims for the same beneficiary on the same day
These claims accounted for $20 million of the 2011 payments for EDX tests. Shockingly, six physicians billed for an average of 32 EDX tests for the same beneficiary on the same day!
The study found, among other things, that 38% of physicians with “questionable billing” were located in just 10 metropolitan areas: New York City, Los Angeles, Houston, Miami, Dallas, Detroit, Chicago, Washington D.C., Phoenix, and Baltimore. Based on their findings, the OIG made three recommendations to CMS:
Increase monitoring of billing for EDX tests (suggesting CMS adopt AANEM’s recommendations for the maximum number of EDX tests that should be performed)
Provide additional guidance and education to physicians re: EDX test (including educating physicians on the need to perform NCSs in conjunction with needle EMGs)
Take appropriate action re: physicians identified as having inappropriate or questionable billing.
CMS responded by partially concurring with the first two recommendations and concurring with the third. CMS also agreed to share the report with its Recovery Auditors.
More information, including the full report, can be found here