Mountain State Medical Policy Bulletin
Section: Diagnostic Medical
Number: M-5
Topic: Tensilon Test
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Tensilon testing is an integral part of the doctor's medical care and is not eligible as a distinct and separate service. If tensilon testing is reported on the same day as medical care, and the charges are itemized, combine the charges and pay only the medical care. Payment for the medical care performed on the same date of service includes the allowance for the tensilon testing. A participating, preferred, or network provider cannot bill the member separately for the tensilon testing in this case.

If the tensilon testing is performed independently, process it under the appropriate code(s).

Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the tensilon testing. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

Payment for tensilon tonography should be processed under procedure code 92120.

Description

Tensilon testing (95857, 95858) is carried out by means of an intravenous injection of tensilon (edrophonium chloride) followed by observation of the patient for increased or decreased ocular muscle function. It is used mainly for the diagnosis of myasthenia gravis.

Tensilon tonography differs from routine tensilon testing in that a tonogram is used to measure intraocular pressure. Tensilon tonography is done only when the routine tensilon testing is equivocal or inconclusive.

Procedure Codes

921209585795858   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.