Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57478)

CMS National Coverage PolicyCode of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who uses the results in the management of the beneficiary's specific medical problem.Federal Register:Federal Register Vol. 62, 59047, Supervision of Diagnostic Tests, describes the degree of physician supervision required for diagnostic tests.CMS Publications:CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2:160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)Program Memorandum Carriers Transmittal B-01-28 Change Request 850, describes tests that may be performed by PTs with ABPTS certificationCMS Publication 100-2.Medicare Benefit Policy Manual, Chapter 15, Section 80: Requirements for Diagnostic Tests.Transmittal 2663 Change Request 8169 April Update to the CY 2013 Medicare Physician Fee Schedule Database (MPFSDB)Italicized font-represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated Local Coverage Determination (LCD) L34594 Nerve Conduction Studies and Electromyography.I. Coding GuidelinesA. Evaluation/Management (E/M)Usually an E&M service is included in the exam performed just prior to and during nerve conduction studies and/or electromyography. If the E&M service is a separate and identifiable service, the medical record must document medical necessity and the CPT code must be bill with a modifier 25.A clinical history from the referral source must indicate the need for testing. Such data containing pertinent clinical information must be attainable for review in instances where the need for a test may come under scrutiny. Absolute inclusive or exclusive criteria for performance of a diagnostic test are difficult to enumerate.B. Nerve Conduction StudiesThe table below provides a reasonable maximum number of studies per diagnostic category necessary for a provider to arrive at a diagnosis in 90% of patients with that final diagnosis.The appropriate number of studies to be performed is left to the judgment of the provider performing the evaluation; however, in the small number of cases, which require testing in excess of the numbers listed in the table, the provider should be able to provide supplementary documentation to justify the additional testing.In some situations, it may be necessary to test an asymptomatic contralateral limb to establish normative values for an individual patient. Documentation must support the medical necessity of the additional test.Codes 95907-95913 describe one or more nerve conduction studies. A single conduction test is defined as a sensory conduction test, a motor conduction test with or without an F wave test, or an H-reflex test. Each type of study (sensory, motor with or without F wave, H reflex) for each nerve is counted as a distinct study when determining the number of studies billed.Each type of study is counted only once when multiple sites on the same nerve are stimulated and recorded. The number of tests (sensory, motor with or without F wave, H reflex) per nerve should be added to determine the code to be billed.Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Procedures Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore, if authorized by state law Physical Therapists are allowed the technical portion and professional component of the test according to the description of 7A.7A = Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.77 = Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without certification under direct supervision of a physician (TC only; PC always physician).These changes are effective January 1, 2013.Appendix J from CPT codebookIndicationsLimbs Studied by Needle EMG95860-95864,95867-95870,95885-95887Nerve Conduction StudiesTotal nerves studied95907-95913Neuromuscular junctiontesting (Repetitivesimulation 95937)Carpal Tunnel unilateral17_Carpal Tunnel bilateral210_Radiculopathy27_Mononeuropathy18_Polyneuropathy/ Mononeuropathy Multiplex310_Myopathy242Motor Neuropathy (e.g., ALS)462Plexopathy212_Neuromuscular Junction243Tarsal Tunnel Syndrome (unilateral)18_Tarsal Tunnel Syndrome (bilateral)211_Weakness, fatigue, cramps, or twitching (local)272Weakness, fatigue, cramps, or twitching (general)482Pain, numbness, or tingling (unilateral)19_Pain, numbness, or tingling (bilateral)212_C. ElectromyographyUse EMG codes 95860-95864 and 95867-95870 when no nerve conduction studies (95907-95913) are performed on that day.Use 95885, 95886, and 95887 for EMG services when nerve conduction studies (95907-95913) are performed on the same day.To bill these codes, extremity muscles innervated by three nerves (for example, radial, ulnar, median, tibial, peroneal, femoral, not sub branches) or four spinal levels must be evaluated; a minimum of five muscles must have been studied.CPT Code 95869 - Needle electromyography; thoracic paraspinal musclesCPT code 95869 should be used to bill a limited EMG study of specific muscles. Examinations confined to distal muscles only, such as intrinsic foot or hand muscles, will be reimbursed as Code 95869 and not as 95860-95866.Use CPT Code 96869 to study thoracic paraspinal muscles between T3 and T11.One unit can be billed, despite the number of levels studied or whether unilateral or bilateral.CPT Code 95870 Needle electromyography, other than paraspinalCPT code 95870 is used for limited testing of specific muscles during an examination. This code should be used only when the muscles tested do not fit more appropriately under another CPT code.CPT code 95870 can be billed at one unit per extremity (one limb, arm or leg), when fewer than five muscles are examined.It can also be used for examining non-limb (axial) muscles (e.g., intercostal, abdominal wall, cervical and lumbar paraspinal muscles (unilateral or bilateral) regardless of the number of levels tested. However, it should not be billed when the paraspinal muscles corresponding to extremity are tested, and when the extremity codes 95860, 95861, 95863, or 95864 are reported.CPT Code 95933 - Blink ReflexesRecordings should be made bilaterally with both ipsilateral and contralateral stimulation.The report of this study should include the presence or absence of the R1 and R2 components.CPT Code 95937 - Neuromuscular Junction StudiesRepetitive stimulation studies are used to identify and to differentiate disorders of the NMJ. This test consists of recording muscle responses to a series of nerve stimulus (at variable rates), both before, and at various intervals after, exercise or transmission of high-frequency stimuli.These codes may be used in association with motor and sensory NCSs of the same nerves and are reimbursed separately.When this study is performed, the providers report should note characteristics of the test, including the rate of repetition of stimulations, and any significant incremental or decremental response.II. Reasons for Denial in addition to those stated in LCDThe report(s) did not include the required numerical data specifically, the amplitude, latency, and velocity gathered during nerve conduction studies.Descriptions of F-wave without reference to a corresponding motor conduction data; pattern-setting unilateral H-reflex measurements; separate E/M charges without documentation requested from the referral source.Surface and macro EMGs will not be paid.Failure to submit, upon request or when request an informal review, a clinical history indicating the need for testing.Absence of a clinical history, preferable written by the referral source, indicating the need for the test.Absence of documentation to support repeated testing on the same beneficiary.Testing every beneficiary referred for pain.Needle electromyographic (EMG) codes 95860- 95870, and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law Physical Therapists are allowed the technical portion of the test according to the description of 6A. Definition below:6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.Needle electromyographic (EMG) code 95872 has the designation of 66 for the technical portion of the test. Definition below:66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.CMS long-standing policy that the concept of physician supervision does not apply (PSI of 09) to these PT-designated diagnostic services, which allows payment to be made for the PC or global code to the ABPTS-PT, excepted by regulation, as long as it is legal for the ABPTS-PT to provide the service in that state, and the TC has been either personally performed by the ABPTS-PT or the PT without the ABPTS certification has met the supervision requirements for the technical component portion of the service consistent with the applicable supervision indicator.III. CommentsCertain less than optimal practices are discouraged, and may invite review. They include: exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions; definitive diagnostic conclusions based on paraspinal EMG in regions bearing scar of past surgeries (e.g., previous laminectomies); pattern-setting limited limb muscle examinations, without paraspinal muscle testing for diagnosis of radiculopathies, narrative reports without data, and premature EMG testing after trauma when EMG changes may not have taken place.There are situations in which EMG and nerve conduction studies can be valuable in a relatively acute situation with or without trauma, even though full-blown EMG changes may not yet have taken place. An example is, to assess the presence of pre-existing injury or disease after trauma or in the evaluation of some non-traumatic conditions, such as suspected Guillain-Barre syndrome.Frequency of testing is a difficult issue to answer. Clinical justification, rather than an algorithm, should be the determinant in these instances. While this removes any recipe-style limits, it also calls for clear responsible and evidence-based documentation for any repeat study. Such a guideline applies to all studies including those for patients(s) under medical, surgical or rehabilitative treatment, (ii) for neuropathy and (iii) for patients with chronic renal failure and/or dialysis.Physical Therapists Performing EMGsProgram Memorandum Transmittal B-01-28/Change Request 850 sets forth revised levels of physician supervision required for diagnostic tests payable under the Medicare Physician Fee Schedule. Effective July 1, 2001, certain codes in the range of CPT 95860-95937 were assigned new supervision levels (21, 22, 6a, 66, 77 or 77a). This implementation date would make it possible for physical therapists to acquire the certification required to perform these services without supervision. A physical therapist who is presently certified by the American Board of Physical Therapy Specialties can perform procedures assigned level of 21, 22, 66, 6a, 77, or 77a without supervision. These numeric levels assigned to the CPT codes are listed in the Medicare Physician Fee Schedule Database (MFSDB).Physical therapists who do not possess the ABPTS (American Board of Physical Therapy Specialties) certification by July 1, 2001, may continue to furnish those tests that require the certification if they have been furnishing such diagnostic tests prior to May 1, 2001.Payment will be based on the Medicare Physician Fee Schedule level of supervision designation.Nerve conduction code 95905 does not have one of the above designations and is therefore not allowed by Physical Therapists.Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Procedures Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore, if authorized by state law Physical Therapists are allowed the technical portion and professional component of the test according to the description of 7A which is included in this Billing and Coding Article.