Electrodiagnostic techniques are clinically useful tools, which help to establish diagnoses and/or assess treatment responses of neurological or muscular conditions. They are also used to monitor neurologic function during neurosurgical procedures.

Nerve Conduction Studies
NCS measure action potentials recorded over the nerve or from an innervated muscle. Nerve conduction velocities (NCV), one aspect of NCS, are measured between two sites of stimulation, or between a stimulus and a recording site. Either surface or needle electrodes can be used. F-wave studies are often performed in conjunction with motor NCS. H-reflex studies involve both sensory and motor nerves and their connections with the spinal cord. These studies are useful in detecting pathology in the proximal segments.

NCS (codes 95900-95905) are performed to assess the integrity of and diagnose diseases of the peripheral nervous system. These procedures are performed by the physician alone or by a technologist under the direct supervision of the physician. The devices used must be capable of recording amplitude, duration, and response configuration (motor NCV) and latency and sensory nerve action potential amplitudes (sensory NCV).

Testing by portable or hand held devices is not covered.

NCS can help to localize an abnormality and distinguish one variety of neuropathy from another. The following are examples of the major uses for NCS:

1. Focal neuropathies or compressive lesions such as carpal tunnel syndrome, ulnar neuropathies or root lesions, for localization.
   
   
2. Traumatic nerve lesions, for diagnosis and prognosis.
   
   
3. Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic, metabolic, inflammatory, or immune.
   
   
4. Repetitive nerve stimulation in diagnosis of neuromuscular junction disorders such as myasthenia gravis, myasthenic syndromes.

Electromyography
EMG is the study of intrinsic electrical properties of skeletal muscle utilizing a needle electrode inserted into muscles of interest. EMG is usually performed in conjunction with NCS. Unlike NCS, however, EMG testing relies on both auditory and visual feedback to the electromyographer who must concurrently determine and adjust the appropriate sites for needle insertion. 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.

According to the statutes of West Virginia, needle electromyography is a physician service and must therefore be performed by a physician or under the direct supervision of a physician. Coverage is allowed for the clinical indications listed in the policy when performed or supervised by a physician. The physician must have successfully completed training in electromyography in an institution which has a nationally accredited residency or fellowship program in neurology or physical medicine and rehabilitation. These credentials must be available for review in the event of a pre- or post-payment review.

These codes refer to needle testing done with devices capable of recording motor unit recruitment, amplitude, configuration, and spontaneous and insertional activity. Both EMGs and NCVs are often required for a clinical diagnosis of peripheral nervous system disorders. Performance of one does not eliminate the need for the other.

EMG testing by portable hand held devices or using surface electrodes is not covered.

A carefully performed EMG may distinguish neurogenic disorders from myopathic disorders. Below is a list of common disorders where an EMG, in tandem with properly conducted NCS, will be helpful in diagnosis:

1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions.
   
   
2. Radiculopathy - cervical, lumbosacral.
   
   
3. Mono/polyneuropathy - metabolic, inflammatory degenerative, hereditary.
   
   
4. Myopathy - including poly- and dermatomyositis, diabetic, myotonic and congenital myopathies.
   
   
5. Plexopathy - idiopathic, trauma, infiltration.
   
   
6. Neuromuscular junction disorders such as myasthenia gravis. Single fiber EMG (Code 95872) is of special value here.
   
   
7. Localization for botulinum toxin or phenol injections in selected cases.

It is not medically necessary to perform isolated studies in the following situations: exclusive testing of intrinsic foot muscles in the evaluation of proximal signs or symptoms; 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; narrative reports without data; and premature EMG testing after trauma when EMG changes may not have taken place. EMG and NCV are not routinely performed as first order diagnostic tests for limb pain resulting from immediate antecedent trauma or acute bone injury.

Somatosensory Testing
Somatosensory evoked potential testing (SEP) is a noninvasive diagnostic technique in which peripheral nerves are stimulated and the response to these stimuli is monitored by electrodes placed externally over appropriate parts of the peripheral nervous system, spinal cord and scalp. Computer averaging and interpretation of these responses provide information as to transmission in and integrity of pathways in the peripheral and central nervous system concerned with the stimuli. SEP is sometimes performed during surgery on the brain or spinal cord to help localize critical anatomic sites.

SEP is useful in localizing the anatomic sites of somatosensory pathway lesions: axonal loss or demyelination. A common use for this procedure is intraoperative testing during intracranial or spinal cord procedures where there is potential for injury. (Example: fusion of a C1-C2 fracture or thalamotomy). This procedure can also be used in other places of service to evaluate disorders such as multiple sclerosis, tumors, trauma, myoclonus or coma. It is not necessary during uncomplicated laminectomy or spinal fusion procedures. Intraoperative testing performed by a hospital technician is not covered. Interpretations by the operating surgeon are not separately reimbursed. It is expected that primary neurologists or neurosurgeons will bill these codes. SEP and Dermatomal SEP for the evaluation of nerve root disorders or acute radiculopathy are still considered investigational and are therefore not covered.

Late Responses: H-Reflex and F-Wave Studies
Late responses are performed to evaluate nerve conduction in more proximal portions of the nerve inaccessible to direct assessment using conventional techniques. These studies provide information in the evaluation of suspected radiculopathies, plexopathies, polyneuropathies, and proximal mononeuropathies, and in some cases they may be the only abnormal study.

Neuromuscular electrodiagnostic testing performed for non-covered indications will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

The number of nerves tested should be the minimum necessary to address the clinical issue being evaluated. In almost all studies this will appropriately include evaluation of 1 or more nerves that have normal test results.

An Evaluation/Management (E/M) service should not be charged in addition to EMG-NCS codes when the studies are done at the request of a referring physician and a separate consultation was not requested. However, in complex cases where the provider must obtain additional history and perform an exam in order to determine appropriate testing, an E/M service may be billed. The report must include pertinent data obtained, and the medical record documentation must support the level of visit billed. Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the EMG-NCS. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

Documentation Requirements

The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available on request.

The number of limbs or areas tested should be the minimum needed to evaluate the patient’s condition. Repeat testing should be infrequent.

Credentials of providers billing for needle electromyography must be available on request. A qualified physician if performed incident to a physician’s service must directly supervise these procedures.

The following bullets summarize the reasonable maximum number of studies per diagnostic category necessary for a physician to arrive at a diagnosis in 90% of patients with that final diagnosis. In simple straightforward cases, fewer tests will be necessary, particularly when the most critical tests are normal. In the small number of cases that require testing in excess of these numbers, the physician must be able to justify the additional testing with supplementary documentation.

Carpal Tunnel (unilateral)

• Needle EMG - 1 test
• Codes 95900/95903 Motor NCS with or w/o F-wave – 3 tests
• Code 95904 Sensory NCS – 4 tests

Carpal Tunnel (bilateral)

• Needle EMG - 2 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 4 tests
• Code 95904 Sensory NCS – 6 tests

Radiculopathy

• Needle EMG - 2 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 3 tests
• Code 95904 Sensory NCS – 2 tests
• Codes 95934/95936 H-Reflex – 2 tests

Mononeuropathy

• Needle EMG - 1 test
• Codes 95900/95903 Motor NCS with or w/o F-wave – 3 tests
• Code 95904 Sensory NCS – 3 tests
• Codes 95934/95936 H-Reflex – 2 tests

Polyneuropathy/Mononeuropathy Multiplex

• Needle EMG - 3 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 4 tests
• Code 95904 Sensory NCS – 4 tests
• Codes 95934/95936 H-Reflex – 2 tests

Myopathy

• Needle EMG - 2 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 2 tests
• Code 95904 Sensory NCS – 2 tests
• Code 95937 NMJ Testing – 2 tests

Motor Neuronopathy

• Needle EMG - 4 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 4 tests
• Code 95904 Sensory NCS – 2 tests
• Code 95937 NMJ Testing – 2 tests

Plexopathy

• Needle EMG - 2 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 4 tests
• Code 95904 Sensory NCS – 6 tests
• Codes 95934/95936 H-Reflex – 2 tests

Neuromuscular Junction

• Needle EMG - 2 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 2 tests
• Code 95904 Sensory NCS – 2 tests
• Code 95937 NMJ Testing – 3 tests

Tarsal Tunnel (unilateral)

• Needle EMG - 1 test
• Codes 95900/95903 Motor NCS with or w/o F-wave – 4 tests
• Code 95904 Sensory NCS – 4 tests

Tarsal Tunnel (bilateral)

• Needle EMG - 2 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 5 tests
• Code 95904 Sensory NCS – 6 tests

Weakness, Fatigue, Cramps or Twitching (focal)

• Needle EMG - 2 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 3 tests
• Code 95904 Sensory NCS – 4 tests
• Code 95937 NMJ Testing – 2 tests

Weakness, Fatigue, Cramps or Twitching (general)

• Needle EMG - 4 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 4 tests
• Code 95904 Sensory NCS – 4 tests
• Code 95937 NMJ Testing – 2 tests

Pain, Numbness or Tingling (unilateral)

• Needle EMG - 1 test
• Codes 95900/95903 Motor NCS with or w/o F-wave – 3 tests
• Code 95904 Sensory NCS – 4 tests
• Codes 95934/95936 H-Reflex – 2 tests

Pain, Numbness or Tingling (bilateral)

• Needle EMG - 2 tests
• Codes 95900/95903 Motor NCS with or w/o F-wave – 4 tests
• Code 95904 Sensory NCS – 6 tests
• Codes 95934/95936 H-Reflex – 2 tests

NOTE:

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.

The following coding guidelines are specific to the Neuromuscular Electrodiagnostic Testing LCD:

• Of the codes listed in this policy, only H-reflex studies (Codes 95934, 95936) are classified as unilateral procedures that may be billed with modifier 50 when performed bilaterally.
  
  
• Services can be performed in the office, hospital or nursing home. For codes 95860-95864, only one unit of service should be billed. This covers all muscles tested including the related paraspinal muscles and recording of motor unit recruitment, amplitude and configuration both at rest and with muscle contraction.
  
  
• Code 95869 should be used for the study of thoracic paraspinal muscles between T3 and T11.
  
  
• Code 95870: Use this code for sampling muscles other than the paraspinals associated with the extremities that have been tested. This code should not be billed when the paraspinal muscles corresponding to an extremity are tested and when the extremity code 95860, 95861, 95863, or 95864 is also billed.
  
  
• Codes 95860-95864: 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.
  
  
• Code 95920 is reported once per hour for ongoing electrophysiologic testing and monitoring. It only includes the time distinct from performance or interpretation of the specific baseline electrophysiologic study. The baseline electrophysiologic study is separately reported. The operating surgeon may not report these services.
  
  
• Code 95904 must not be used when submitting a claim for Current Perception Threshold/Sensory Nerve Conduction Threshold Testing (sNCT).
  
  
• Report code 95900- 95904 one time when multiple sites on the same nerve are stimulated or recorded.
  
  
• In order to report multiple units of codes 95900-95904 for studies of two or more branches of a given motor, sensory, or mixed nerve, both the stimulating and recording electrodes must be moved to different locations.
  
  
• Codes 95900 and 95903 may be submitted on the same day for the same patient when multiple nerves are tested, some with and some without F-waves. CPT modifier 59 must be used in this situation.  Codes 95900 and 95903 may not be submitted for the same nerve on the same day for the same patient.

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 1862(a)(1)(A) states that no 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 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Electromyography

Nerve Conduction Studies

Somatosensory Testing

Reflex Tests

Use of these codes does not guarantee reimbursement. The patient’s medical record must document that the coverage criteria in this policy have been met.

Codes 95867 and 95868 (Cranial EMG):

Codes 95860-95865; 95869-95872 (Non cranial EMG and NCS):

Codes 95900; 95904; 95905; 95937 (Non cranial EMG and NCS):

Codes 95903 and 95936 (F-waves and H- reflexes)

Code 95934 (H-reflex)

Codes 95920; 95925-95927: (Intraoperative testing; Somatosensory evoked potentials)

a. Codes 95920; 95925; 95927: Upper Limbs; Head and Trunk

b. Codes 95920; 95926: Lower Limbs

Codes 95933: (Non cranial EMG and NCS)