Healthcare Fraud Shield’s Latest Article: Finding the Dysfunction in Autonomic Nervous System Testing

11 May
What is the autonomic nervous system?
The autonomic nervous system (ANS) regulates a wide variety of body system processes that take place without having to think about it, such as heartbeat, breathing, body temperature, metabolism, blood circulation, and digestion to name a few. The ANS consists of three parts: the sympathetic, parasympathetic, and enteric (the digestive system only). The sympathetic division regulates the Fight or Flight response, increasing the availability of energy, heart rate, and dilating eye pupils. The parasympathetic division helps to protect and recover normal body functions, slowing the heart rate and reducing pupils. The sympathetic and parasympathetic systems have opposite functions, responding and recovery after a response.

What causes problems with autonomic nervous system?
Autonomic disorders can be caused by damage to the autonomic nerves, and parts of the brain that control body systems. Some common disorders that cause damage include diabetes, peripheral nerve disorders, and Parkinson disease. Less common: Autonomic neuropathies, spinal cord disorders, some viral infections, and injury to nerves in the neck.

What kinds of tests are used to diagnose autonomic nervous system disorders?
Cardiovagal function Test: Measuring heart rate variability, heart rate response to deep breathing and Valsalva maneuver.
Vasomotor Adrenergic Function Test: Measuring blood pressure response to standing, Valsalva maneuver, hand grip, and with a tilt table.
Tilt Table Test: The patient is strapped to a motorized table that moves into an upright position while measuring changes in the patient’s blood pressure and heart rate.
Quantitative Sudomotor Axon Reflex Test (QSART): This test measures autonomic nerves that control sweating by utilizing mild electrical stimulation on the skin by iontophoresis. Measuring the volume of sweat produced.
Thermoregulatory Sweat Test (TST): The core body temperature is raised. The degree and extent of sweat production is then visualized with an indicator dye.

Who can perform autonomic nervous system testing?
Per the American Academy of Neurology (AAN): “We strongly recommend that only physicians with the appropriate training perform and interpret clinical autonomic test results. The United Council of Neurologic Subspecialties has established a board examination as one potential method to certify those individuals with expertise in autonomic disorders.”[1] 

How is this testing billed?
The American Medical Association (AMA) Current Procedural Terminology (CPT) assigns the following procedure codes to ANS testing:
95921: Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including two or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio. 
95922: Vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least 5 minutes of passive tilt. (Do not report 95922 in conjunction with 95921) 
95923: Sudomotor, including one or more of the following quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential.
95924: combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt. (Do not report 95924 in conjunction with 95921 or 95922 ) 
95943: Simultaneous, independent, quantitative measures of both parasympathetic function and sympathetic function, based on time-frequency analysis of heart rate variability concurrent with time-frequency analysis of continuous respiratory activity, with mean heart rate and blood pressure measures, during rest, paced (deep) breathing, Valsalva maneuvers, and head-up postural change. (Do not report 95943 in conjunction with 93040, 95921, 95922, 95924?

What should I look for?
Per the AAN: “A number of automated testing devices have been developed over the past several years and advertised directly to non-neurologists and general practitioners who do not have training or expertise in the autonomic nervous system. Some of these automated devices may also generate patient-specific recommendations for treatment. As a result, physicians who do perform full autonomic testing have seen a large increase in the number of patients erroneously diagnosed with an autonomic disorder. Most physicians without training in the autonomic nervous system do not know enough about many of the rare autonomic disorders to integrate the information supplied by automated devices into the clinical history of the individual in front of them.” [2]

These automated testing devices often do not meet the coding requirements. These codes also require physician interpretation and report, which without the right training may not be diagnostically accurate or meet medical necessity and coding requirements. Most payors will have guidelines around provider qualifications and testing requirements. Make sure to be familiar with your carrier’s policies.

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