Autonomic Nervous System Testing, or ANS testing as it is more commonly known, has drawn increasing amounts of popularity in the last few decades due to the alluring concept of a comprehensive analysis that provides data points highlighting imbalances in the central nervous system and imbalances between the sympathetic vs. parasympathetic systems.
When internal systems suffer imbalances, such as in the case of patients who exhibit autonomic neuropathy, tachycardia, syncope, hypertension, or other cardiac-related conditions, then ANS testing becomes critical to isolate and identify the causes of these conditions. The RM3A device has been a gold standard for this type of testing as it performs a comprehensive twenty-minute test that not only encompasses ANS testing, but also sudomotor testing, which tests for small nerve fiber neuropathies; endothelial testing, which tests the integrity of the lining of the blood vessels; cardio metabolic testing, which tests body mass index or BMI of the patient; and insulin resistance testing to evaluate diabetic and the ever- rising pre-diabetic patients. However, the way in which these tests are run has recently come under scrutiny and where special attention and care must be taken by providers when evaluating these “comprehensive all-in-one testing platforms” (Mayo Clinic Autonomic Neuropathy).
The RM3A measures heart rate variability, and R-R intervals through Plethysmography, more commonly known as PPG’s. In simple language, these are the silver plates that patients stand on and rest their palms on so the equipment can capture various data points and provide a report as to the overall health of the patient’s autonomic nervous system. However, according to closer inspection on CMS Medicare guidelines and regulations, it would seem that Medicare is taking a hardline approach against PPG-based equipment that gather these data points for their final analysis. This may not just be important regarding clinical efficacy for the patient, but may affect bottom line reimbursement from Medicare as well as commercial carriers that eventually follow suit with Medicare guidelines.
Based on information from CMS.gov and Medicare Local Coverage Decision (LCD) documents, it’s clear that any device used to bill for the ANS CPT Codes such as 95921 or 95924 MUST monitor R-R Intervals generated by an ECG Based System. R-R by definition is from an ECG based QRS Complex. LCDs define the “Valsalva Ratio” and the “30:15 Ratio” (lie down-stand up monitoring of R-R interval and blood pressure changes) in more detail than in the less specific general code description shown below. The LCDs explain that the above provocative procedures must be done while the ECG derived R-R Intervals and blood pressure are monitored. It would seem based on these evaluations that PPG testing is insufficient to properly monitor R-R intervals in compliance with the final billing authority LCDs unless an ECG-based testing technology is used.