Draft Article - Billing and Coding: Nerve Conduction Studies and Electromyography (DA54095)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Medicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter 11, Section L-Neurology and Neuromuscular ProceduresArticle TextThis Billing and Coding Article provides billing and coding guidance for Proposed Local Coverage Determination (LCD) DL35081 Nerve Conduction Studies and Electromyography. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Consistent with the LCD, nerve conduction studies (NCSs) without needle electromyography (NEMG) will be allowed for:Individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the following diagnosis codes are reported: G56.01, G56.02, G56.03, G57.51, G57.52 or G57.53.Individuals with significant lymphedema in the affected extremity when the following diagnosis code is reported in addition to the primary diagnosis: I89.0.Individuals treated with anticoagulants when one of the following diagnosis codes are reported in addition to the primary diagnosis: Z79.01 or Z79.02.NCSs and NEMG performed on the same day, for the same patient must be reported on the same claim.Consistent with the LCD, the following services/tests are non-covered. Therefore, when billing these services/tests report the unlisted neurological diagnostic CPT code 95999 appended with the GY modifier (item or service statutorily excluded or does not meet the definition of any Medicare benefit). When submitting claims, providers must provide a description of the service/test in the narrative/remarks field (Item 19) on the CMS-1500 claim form or the electronic equivalent. If a description is not provided in the narrative/remarks field, the claim/service will be rejected.Non-invasive electrodiagnostic (EDX) testing using portable hand-held devices or automated point of care nerve conduction monitoring systems, which are incapable of real-time waveform display and analysisPsychophysical measurements (electrical, vibratory, or thermal perceptions), even though they may involve delivery of a stimulus,are considered part of the physical examination and may not be reported as a separate servicePhysiologic recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor using wearable devices with accelerometers or gyroscopesNEMG for Surface electromyography (SEMG) or Macroelectromyography (macro-EMG)For HCPCS code G0255, refer to the CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 2, Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs).Utilization ParametersStudies performed per day beyond the reasonable maximum number of studies recommended in the Current Procedural Terminology (CPT) Codebook, Appendix J, Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves will be denied. Additional studies may be considered on redetermination.Consistent with the LCD, the following number of tests per 12-month period per diagnosis per provider for repeat EDX assessment are suitable: 1) Two studies for carpal tunnel-unilateral, carpal tunnel-bilateral, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction (NMJ) disorders. 2) Three studies for motor neuron disease and plexopathy.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The patients medical records must clearly document the medical necessity for the test. The indication for ordering the test(s) and a clear diagnostic impression are required in each report. In cases where documentation is requested, a hard copy of waveforms and/or a complete written report with an interpretation of the test, sufficient to support that the test was medically reasonable and necessary must be submitted.Normal findings and abnormalities uncovered during the study should be documented with the nerves and muscles tested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials and interpretation. Expected normal value range for the specific EDX device should also be included.If a patient has had analogous testing performed in the past, documentation should also be included that references the date it was performed as well as results and subsequent management based on those findings.