Indications and Limitations of Coverage and/or Medical Necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Electromyography (EMG) is the study and recording of intrinsic electrical properties of skeletal muscles. This is carried out with a needle electrode, often (but not always) a disposable one. Generally, the electrodes are of two types: monopolar or concentric. EMG testing relies on both auditory and visual feedback to the electromyographer. This testing is also invasive in that it requires needle insertion and adjustment at multiple sites and at anatomically critical areas. The electromyographer depends on ongoing real-time clinical diagnostic evaluation for deciding whether to continue, modify or conclude a test. This requires a knowledge base of anatomy, physiology and neuromuscular diseases.
EMG results reflect not only on the integrity of the functioning connection between a nerve and its innervated muscle but also on the integrity of a muscle itself. The axon innervating a muscle is primarily responsible for the muscle's volitional contraction, survival and trophic functions. Thus, interruption of the axon will alter the EMG.
Neurogenic disorders are distinguishable from myopathic disorders by a carefully performed EMG. For example, both polymyositis and ALS (Amyotrophic Lateral Sclerosis) produce manifest weakness. The former carries a very different prognosis and treatment than the latter. An EMG is very valuable in making this distinction. Similarly, classification of nerve trauma into axonal vs. demyelinating categories, with corresponding differences in prognoses, are possible with EMG. An EMG may be indicated for the following conditions:
- Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions
- Motor neuron disorders
- Radiculopathy - cervical, lumbosacral
- Mono/polyneuropathy - metabolic, degenerative, hereditary
- Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies
- Plexopathy - idiopathic, trauma, infiltration
- Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG ( 95872) is of special value here.
- At times, before Botulism A toxin injection, for localization
- At times, prior to injection of phenol or other substances for nerve blocking or chemodenervation
The necessity and reasonableness of the following uses of EMG studies have not been established:
- 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 a diagnosis of radiculopathies
- Premature EMG testing after trauma when EMG changes may not have taken place
- Multiple uses of EMG in the same patient at the same location of the same limb for the purpose of optimizing botulinum toxin injections
Electromyographic studies performed with surface electrodes instead of needle technology and nerve conduction studies that do not provide real-time conduction, amplitude and latency/velocity data are not to be billed with the standard electrodiagnostic codes (i.e., code
95860 for EMG or
95907-95913 for nerve conduction studies).
A "Surface" EMG (
95999) is not the same as a conventional EMG and involves the use of a probe that is passed over the surface of the skin in order to measure electrical muscle activity. This method of EMG testing is considered investigational and is not a covered service. Surface and macro EMG's will be denied as not medically necessary.
Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recordable over the nerve or from an innervated muscle. With this technique, nerve conduction velocities are measured between two sites of stimulation, or between a stimulus and a recording site. Nerve conduction studies are frequently performed together with electromyography (EMG). Nerve conduction velocity measurement (NCV) is one aspect of a nerve conduction study.
Assessment of conduction in proximal segments of a peripheral nerve is described by H-reflex, F-waves and blink testing. (Current evidence in standard peer-reviewed medical journals does not support the use of F waves, in isolation, to diagnose radiculopathy) This is to be contrasted with the investigation of distal peripheral nerves, which is accomplished by nerve conduction studies.
Results of the NCV reflect on the integrity and function of (I) the myelin sheath (Schwann cell derived insulation covering an axon) and (II) the axon (an extension of neuronal cell body) of a nerve. Interruption of axon and dysfunction of myelin will both affect NCV results. Nerve conduction studies are of two broad types: Sensory and Motor.
Each descriptor (code) can be reimbursed only once per nerve, or named branch of a nerve, regardless of the number of sites tested or the number of methods used on that nerve. For instance, testing the ulnar nerve at wrist, forearm, below elbow, above elbow, axilla and supraclavicular regions will all be considered as a single unit test (reported as
95907). Motor and sensory nerve testing are considered separate tests. For sensory nerve testing by either the orthodromic and antidromic methods, only one unit of charge will be paid when the same nerve is evaluated by these different methods.
Screening testing for polyneuropathy of diabetes or endstage renal disease (ESRD) is NOT covered. Testing for the sole purpose of monitoring disease intensity or treatment efficacy in these two conditions is also not covered.
Psychophysical measurements (current, vibration, thermal perceptions), even though they may involve delivery of a stimulus, are not covered.
Examination using portable hand-held devices, which are incapable of real-time wave-form display and analysis, will be included in the E/M service. They will not be paid separately.
Medicare does not expect to receive claims for nerve conduction testing accomplished with discriminatory devices that use fixed anatomic templates (
95905) and computer-generated reports used as an adjunct to physical examination routinely on all patients. CPT code
95905 is payable only once per upper extremity limb studied per patient per year in patients with a high pre-test probability (80% or more) of carpal tunnel syndrome. This code cannot be billed in conjunction with any other nerve conduction codes on the same patient on the same day. Medicare expects that instruments and electrodes used for these tests have relevant FDA approvals and published peer-reviewed scientific data to support their use.
Both NCV and EMG studies must provide a number of response parameters in a real-time fashion to facilitate provider interpretation. Those parameters include amplitude, latency, configuration and conduction velocity. Medicare does not accept diagnostic studies that do not provide this information or those that provide delayed interpretation as substitutes for nerve conduction studies. Raw measurement data obtained and transmitted trans-telephonically or over the Internet, therefore, does not qualify for the payment of the electrodiagnostic service codes included in this LCD.
The electromyographer must have knowledge of anatomy, physiology, and neuromuscular diseases, as well as awareness of the influence of age, temperature and body height on the results. Since these tests may produce anxiety and stress, an exquisite awareness of patient's comfort and sensitivity are essential. Persons performing electrodiagnosis should be appropriately trained and qualified.
In the majority of situations, the performance of NCSs without needle EMG has the potential of compromising patient care. It is important that the NCSs and the needle EMG examinations be performed together and their results integrated into a unified diagnostic impression. The performance or interpretation of NCS separately from the needle EMG component of the testing should clearly be the exception. It is in the best interest of patients, in the majority of situations, for the needle EMG and the NCS examination to be conducted and interpreted at the same time. Interpretation of NCS data alone, absent face-to-face patient interaction and control over the process may also provide substandard care.
The performance of EMG-NCV studies by non-physicians is governed by the scope of practice defined by the State and the appropriate level of supervision described in the Federal Register of November, 1997. In the state of New Jersey only a physician may perform EMG studies.
CMS National Coverage Policy:
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
CMS Internet-Only Manual (IOM), Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 160.23 concludes after reconsideration (2004) that there continues to be insufficient scientific or clinical evidence to consider the sNCT test and the device used in performing this test as reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law.
Program Memorandum B-01-28 dated April 19, 2001, Medicare Carriers Manual Change Request 1756, dated September 27, 2001
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