LCD for Nerve Conduction Studies (NCS)/Electromyography (EMG) (L26869) Contractor Information

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1 Page 1 of 24 Deborah Rondeau From: Saved by Windows Internet Explorer 7 Sent: Saturday, August 23, :49 PM Subject: FUTURE LCD : Nerve Conduction Studies (NCS)/Electromyography (EMG) (L26869) LCD for Nerve Conduction Studies (NCS)/Electromyography (EMG) (L26869) Contractor Information Contractor Name National Government Services, Inc. Contractor Number Number Type State(s) FI IN FI IL FI KY FI ME FI MA FI NH, VT FI CT, DE, NY FI OH FI WI FI MI FI VA, WV Carrier IN Carrier KY Carrier NJ MAC CT Part A MAC CT Part B MAC NY Part A MAC NY Part B MAC NY- Part B MAC NY Part B Contractor Type Carrier FI MAC Part A MAC Part B LCD Information LCD ID Number

2 Page 2 of 24 L26869 LCD Title Nerve Conduction Studies (NCS)/Electromyography (EMG) Contractor's Determination Number L26869 (R1) AMA CPT / ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Balanced Budget Act of 1997, Chapter 1, Section 4317.b. indicates that diagnostic information must be provided by the ordering physician or practitioner to allow payment to be made to the performing entity. Code of Federal Regulations: 42 CFR Section 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.

3 Page 3 of 24 Federal Register: Federal Register Vol. 62, 59047, Supervision of Diagnostic Tests, describes the degree of physician supervision required for diagnostic tests. CMS Publications: Pub , Medicare National Coverage Determinations, Chapter 1, Part 2: Sensory Nerve Conduction Threshold Tests (sncts) Primary Geographic Jurisdiction Number Type State(s) FI IN FI IL FI KY FI ME FI MA FI NH, VT FI CT, DE, NY FI OH FI WI FI MI FI VA, WV Carrier IN Carrier KY Carrier NJ MAC CT Part A MAC CT Part B MAC NY Part A MAC NY Part B MAC NY- Part B MAC NY Part B Secondary Geographic Jurisdiction See Other Comments Oversight Region CMS Region I, II, III, V Original Determination Effective Date For services performed on or after 07/01/2008 Original Determination Ending Date Not applicable

4 Page 4 of 24 Revision Effective Date For services performed on or after 07/18/2008 Revision Ending Date Not applicable Indications and Limitations of Coverage and/or Medical Necessity This LCD consolidates and replaces all previous policies and publications on this subject by the carrier and fiscal intermediary predecessors of National Government Services (AdminaStar Federal, Anthem Health Plans of New Hampshire, Associated Hospital Service, Empire Medicare Services, Group Health Incorporated (GHI), HealthNow, First Coast Service Options, and United Government Services). This revised LCD is effective for all National Government Services jurisdictions on July 18, 2008 with these exceptions: for Connecticut Part B the LCD is effective on August 1, 2008; for Upstate New York Part B, the LCD is effective on September 1, 2008; and for New York and Connecticut Part A, the LCD is effective on November 14, For New York Part A (contract 00308), the content of this LCD is currently in effect but the LCD will be transferred to the J-13 contract number on November 14, Abstract: The electrodiagnostic evaluation is an extension of the neurologic portion of the physical examination. Both require a detailed knowledge of a patient and his/her disease. Training in the performance of electrodiagnostic procedures in isolation of knowledge about clinical diagnostic and management aspects of neuromuscular diseases, may not be adequate for proper performance of an electrodiagnostic evaluation and correct interpretation of electrodiagnostic test results. Without awareness of the patterns of abnormality expected in different diseases and knowledge that the results of nerve conduction studies (NCS) and electromyography (EMG) may be similar in different diseases, diagnosis solely by EMG-NCS findings may be both inadequate and ultimately be detrimental to the patient. Guidelines about proper qualifications for qualified health care professionals performing electrodiagnostic evaluations have been developed and published by AANEM (American Association of Neuromuscular and Electrodiagnostic Medicine) and other medical organizations, including the AMA, the American Academy of Neurology, the American Academy of Physical Medicine and Rehabilitation, American Neurological Association, the American Board of Physical Therapy Specialists in Neurophysiology, and the Department of Veterans Affairs. These guidelines will be considered by National Government Services when evaluating a health care professional as qualified to perform nerve conduction studies and electromyography. Both EMGs and NCSs are usually required for a clinical diagnosis of peripheral nervous system disorders. Performance of one type of testing does not eliminate the need for the other. The intensity and extent of testing with EMG and NCS are matters of clinical judgment developed after the initial pre-test evaluation, and later modified during the testing procedure.

5 Page 5 of 24 Decisions to continue, modify or conclude a testing rely on knowledge of anatomy, physiology and neuromuscular diseases. Ongoing real-time assessment of data is required during the clinical diagnostic evaluation and especially during EMG examination. Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation which are recordable over the nerve or from an innervated muscle. With this technique, responses are measured between two sites of stimulation, or between a stimulus and a recording site. Nerve conduction studies are of two general types: sensory and motor. Either surface or needle electrodes can be used to stimulate the nerve or record the response. Axonal damage or dysfunction generally results in loss of nerve or muscle potential response amplitude; whereas, demyelination leads to prolongation of conduction time and slowing of conduction velocity. Obtaining and interpreting NCS results requires extensive interaction between the performing qualified health care professional and patient, and is most effective when both obtaining raw data and interpretation are performed concurrently on a real-time basis. Results of the NCS 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 NCS results. It is often also valuable to test conduction status in proximal segments of peripheral nerves. This assessment can be accomplished by H-reflex, F-wave and blink reflex testing. These proximal segments include the first several centimeters of a compound nerve emerging from the spinal cord or brainstem. H-reflex, F-waves and Blink reflex testing (CPT 95934, 95936, 95903, 95933) accomplish this task better than distal NCS (CPT 95900, 95904). Electromyography (EMG) is the study and recording of intrinsic electrical properties of skeletal muscles. This is carried out with a needle electrode. Generally, the electrodes are of two types: monopolar or concentric. EMG is undertaken together with NCS. Unlike NCS, however, EMG testing relies on both auditory and visual feedback to the electromyographer. This testing is also invasive in that it requires needle electrode insertion and adjustment at multiple sites, and at times anatomically critical sites. As in NCS during EMG studies the electromyographer depends on ongoing real-time interpretation based knowledge of clinical diagnosis being c evaluated to decide whether to continue, modify, or conclude a test. This process requires knowledge 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. A few prime examples of conditions in which EMG is potentially helpful are disc disease producing spinal nerve dysfunction, advanced nerve compression in peripheral lesions,

6 Page 6 of 24 ALS, polyneuropathy, etc. After an acute neurogenic lesion, EMG changes may not appear for several days to weeks in the innervated muscles. Primary muscle disease such as polymyositis will also alter a normal EMG pattern. Myotonic disorders may show a pattern of spontaneous repetitive discharges on needle exploration. In summary, axonal and muscle involvement are most sensitively detected by EMGs, and myelin and axonal involvement are best detected by NCSs. Indications: Nerve conduction studies (CPT Codes 95900, 95903, 95904, 95933, 95934, 95936) NCS may be helpful in the diagnosis of carpal tunnel syndrome, ulnar neuropathy at the elbow and peripheral polyneuropathies, traumatic nerve damage, and neuromuscular junction disorders like myasthenia gravis. NCS may be indicated in the following clinical scenarios: Focal neuropathies or compressive lesions such as carpal tunnel syndrome, ulnar neuropathies or root lesions, for localization Traumatic nerve lesions, for diagnosis and prognosis Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic, metabolic or immune Repetitive nerve stimulation in diagnosis of neuromuscular junction disorders such as myasthenia gravis, myasthenic syndrome Symptom-based presentations such as pain in limb, weakness, disturbance in skin sensation or paraesthesia when appropriate pre-test evaluations are inconclusive and the clinical assessment unequivocally supports the need for the study The clinical history and examination, carried out before the study, must always describe and document clearly and comprehensibly the need for the planned test, and what the results are expected to contribute that is medically necessary for the ordering physician to diagnose or treat the illness or injury or improve the functioning of a malformed body member. Electromyography (CPT Codes 92265, 95860, 95861, 95863, 95864, 95867, 95868, 95869, 95870, 95872) The presence of damage to the motor nerve cell bodies and peripheral axons is detected by a carefully performed EMG. Neurogenic disorders are distinguishable from myopathic disorders by EMG testing. Below is a list of common disorders in which EMG, in tandem with properly conducted NCS, will be helpful in diagnosis: Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions Radiculopathy-cervical, lumbosacral

7 Page 7 of 24 Polyneuropathy-metabolic, degenerative, hereditary Plexopathy-idiopathic, trauma, infiltration Myopathy-including poly and dermatomyositis, myotonic and congenital myopathies Neuromuscular junction disorders-myasthenia gravis (The advance technique of Single fiber EMG is of especial value here.) At times, immediately prior to Botulinum A toxin injection, for muscle localization At times, immediately prior to injection of phenol or other substances for nerve blocking or chemodenervation for muscle localization Limitations: Nerve Conduction Studies 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 of code or Motor and sensory nerve testing are considered separate tests. Sensory nerve testing should be reported using CPT code 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. Current Perception Threshold/Sensory Nerve Conduction Threshold Test (snct) is not covered by Medicare. This procedure is different and distinct from assessment of nerve conduction velocity, amplitude and latency. It is also different from short-latency somatosensory evoked potentials. Codes designated for eliciting nerve conduction velocity, latency or amplitude, and those designed for short latency evoked potentials are not to be used for snct. The snct has a unique code. Include the code here. Effective October 1, 2002, CMS initially concluded that there was insufficient scientific or clinical evidence to consider the snct test and the device used in performing this test reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. Therefore, snct was noncovered. Based on a reconsideration [in March, 2004] of current Medicare policy for snct, CMS concludes 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. CMS Publication 100-3, Medicare National Coverage Issues Manual, Chapter 1, Section Examination using portable hand-held devices, which are incapable of real-time waveform display and analysis, will be included in the E/M service. They will not be paid

8 Page 8 of 24 separately. Nerve conduction 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. Medicare does not expect to receive claims for nerve conduction testing accomplished with discriminatory devices that use fixed anatomic templates and computer-generated reports used as an adjunct to physical examination routinely on all patients. Electromyography It is expected that providers will use CPT code for sampling muscles other than the paraspinals associated with the extremities, which have been tested. Medicare would not expect to see this code billed when the paraspinal muscles corresponding to an extremity are tested and when the extremity EMG code 95860, 95861, or is also billed. 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 radiculopathy EMG testing shortly after trauma, before EMG abnormalities would have reasonably had time to develop surface and macro EMG s multiple uses of EMG in the same patient at the same location of the same limb for the purpose of optimizing botulinum toxin injections. Other Comments: For claims submitted to the fiscal intermediary: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims. Bill type codes only apply to providers who bill these services to the fiscal intermediary. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must

9 Page 9 of 24 notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for NCS/EMG services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections , , and ; 58 FR 18543, April 7, 2000.) Each practitioner must provide only those service within the scope of practice for each state, e.g., in the state of New Jersey only a physician may perform EMG studies. Coverage Topic Diagnostic Tests and X-Rays Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 12x 13x Hospital-inpatient or home health visits (Part B only) Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) 21x SNF-inpatient, Part A 22x SNF-inpatient or home health visits (Part B only) 23x SNF-outpatient (HHA-A also) 71x Clinic-rural health 85x Special facility or ASC surgery-rural primary care hospital (eff 10/94) Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported

10 Page 10 of 24 under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. Revenue codes only apply to providers who bill these services to the fiscal intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes Other diagnostic services-general classification 0922 Other diagnostic services-electromyelogram 0929 Other diagnostic services-other CPT/HCPCS Codes Nerve Conduction Studies (NCS) NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, WITHOUT F-WAVE STUDY NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, WITH F-WAVE STUDY NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; SENSORY ORBICULARIS OCULI (BLINK) REFLEX, BY ELECTRODIAGNOSTIC TESTING H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD GASTROCNEMIUS/SOLEUS MUSCLE H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD MUSCLE OTHER THAN GASTROCNEMIUS/SOLEUS MUSCLE G0255 CURRENT PERCEPTION THRESHOLD/SENSORY NERVE CONDUCTION TEST, (SNCT) PER LIMB, ANY NERVE Electromyography (EMG) NEEDLE ELECTROMYOGRAPHY; ONE EXTREMITY WITH OR WITHOUT RELATED PARASPINAL AREAS NEEDLE ELECTROMYOGRAPHY; TWO EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS NEEDLE ELECTROMYOGRAPHY; THREE EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS NEEDLE ELECTROMYOGRAPHY; FOUR EXTREMITIES WITH OR WITHOUT

11 Page 11 of 24 RELATED PARASPINAL AREAS NEEDLE ELECTROMYOGRAPHY; LARYNX NEEDLE ELECTROMYOGRAPHY; HEMIDIAPHRAGM NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLE(S), UNILATERAL NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLES, BILATERAL NEEDLE ELECTROMYOGRAPHY; THORACIC PARASPINAL MUSCLES (EXCLUDING T1 OR T12) NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY OF MUSCLES IN ONE EXTREMITY OR NON-LIMB (AXIAL) MUSCLES (UNILATERAL OR BILATERAL), OTHER THAN THORACIC PARASPINAL, CRANIAL NERVE SUPPLIED MUSCLES, OR SPHINCTERS NEEDLE ELECTROMYOGRAPHY USING SINGLE FIBER ELECTRODE, WITH QUANTITATIVE MEASUREMENT OF JITTER, BLOCKING AND/OR FIBER DENSITY, ANY/ALL SITES OF EACH MUSCLE STUDIED ICD-9 Codes that Support Medical Necessity It is the responsibility of the provider to code to the highest level specified in the ICD- 9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination. 138 LATE EFFECTS OF ACUTE POLIOMYELITIS MALIGNANT NEOPLASM OF CRANIAL NERVES MALIGNANT NEOPLASM OF CEREBRAL MENINGES MALIGNANT NEOPLASM OF SPINAL CORD MALIGNANT NEOPLASM OF SPINAL MENINGES SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED BENIGN NEOPLASM OF CRANIAL NERVES BENIGN NEOPLASM OF SPINAL CORD BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR

12 Page 12 of 24 UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED OTHER AND UNSPECIFIED MANIFESTATIONS OF THIAMINE DEFICIENCY DEFICIENCY OF OTHER VITAMINS LIPOPROTEIN DEFICIENCIES GENETIC TORSION DYSTONIA ATHETOID CEREBRAL PALSY OTHER ACQUIRED TORSION DYSTONIA BLEPHAROSPASM OROFACIAL DYSKINESIA SPASMODIC TORTICOLLIS ORGANIC WRITERS' CRAMP OTHER FRAGMENTS OF TORSION DYSTONIA HEREDITARY SPASTIC PARAPLEGIA WERDNIG-HOFFMANN DISEASE SPINAL MUSCULAR ATROPHY UNSPECIFIED KUGELBERG-WELANDER DISEASE OTHER SPINAL MUSCULAR ATROPHY AMYOTROPHIC LATERAL SCLEROSIS PROGRESSIVE MUSCULAR ATROPHY PROGRESSIVE BULBAR PALSY PSEUDOBULBAR PALSY PRIMARY LATERAL SCLEROSIS OTHER MOTOR NEURON DISEASES OTHER ANTERIOR HORN CELL DISEASES ANTERIOR HORN CELL DISEASE UNSPECIFIED SYRINGOMYELIA AND SYRINGOBULBIA VASCULAR MYELOPATHIES SUBACUTE COMBINED DEGENERATION OF SPINAL CORD IN DISEASES CLASSIFIED ELSEWHERE MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE OTHER MYELOPATHY UNSPECIFIED DISEASE OF SPINAL CORD IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY PERIPHERAL AUTONOMIC NEUROPATHY IN DISORDERS CLASSIFIED

13 Page 13 of 24 ELSEWHERE REFLEX SYMPATHETIC DYSTROPHY UNSPECIFIED REFLEX SYMPATHETIC DYSTROPHY OF THE UPPER LIMB REFLEX SYMPATHETIC DYSTROPHY OF THE LOWER LIMB REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE AUTONOMIC DYSREFLEXIA UNSPECIFIED DISORDER OF AUTONOMIC NERVOUS SYSTEM SCHILDER'S DISEASE ACUTE (TRANSVERSE) MYELITIS NOS ACUTE (TRANSVERSE) MYELITIS IN CONDITIONS CLASSIFIED ELSEWHERE IDIOPATHIC TRANSVERSE MYELITIS OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM CONGENITAL DIPLEGIA CONGENITAL HEMIPLEGIA CONGENITAL QUADRIPLEGIA CONGENITAL MONOPLEGIA INFANTILE HEMIPLEGIA OTHER SPECIFIED INFANTILE CEREBRAL PALSY INFANTILE CEREBRAL PALSY UNSPECIFIED QUADRIPLEGIA UNSPECIFIED - QUADRIPLEGIA C5-C7 INCOMPLETE OTHER QUADRIPLEGIA PARAPLEGIA DIPLEGIA OF UPPER LIMBS MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE UNSPECIFIED MONOPLEGIA CAUDA EQUINA SYNDROME WITHOUT NEUROGENIC BLADDER CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER OTHER SPECIFIED PARALYTIC SYNDROME PARALYSIS UNSPECIFIED ATYPICAL FACE PAIN BELL'S PALSY OTHER FACIAL NERVE DISORDERS FACIAL NERVE DISORDER UNSPECIFIED

14 Page 14 of DISORDERS OF PNEUMOGASTRIC (10TH) NERVE DISORDERS OF ACCESSORY (11TH) NERVE DISORDERS OF HYPOGLOSSAL (12TH) NERVE MULTIPLE CRANIAL NERVE PALSIES BRACHIAL PLEXUS LESIONS LUMBOSACRAL PLEXUS LESIONS CERVICAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED THORACIC ROOT LESIONS NOT ELSEWHERE CLASSIFIED LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED NEURALGIC AMYOTROPHY OTHER NERVE ROOT AND PLEXUS DISORDERS UNSPECIFIED NERVE ROOT AND PLEXUS DISORDER CARPAL TUNNEL SYNDROME OTHER LESION OF MEDIAN NERVE LESION OF ULNAR NERVE LESION OF RADIAL NERVE CAUSALGIA OF UPPER LIMB MONONEURITIS MULTIPLEX OTHER MONONEURITIS OF UPPER LIMB MONONEURITIS OF UPPER LIMB UNSPECIFIED LESION OF SCIATIC NERVE MERALGIA PARESTHETICA OTHER LESION OF FEMORAL NERVE LESION OF LATERAL POPLITEAL NERVE LESION OF MEDIAL POPLITEAL NERVE TARSAL TUNNEL SYNDROME LESION OF PLANTAR NERVE CAUSALGIA OF LOWER LIMB OTHER MONONEURITIS OF LOWER LIMB MONONEURITIS OF LOWER LIMB UNSPECIFIED MONONEURITIS OF UNSPECIFIED SITE HEREDITARY PERIPHERAL NEUROPATHY PERONEAL MUSCULAR ATROPHY HEREDITARY SENSORY NEUROPATHY REFSUM'S DISEASE IDIOPATHIC PROGRESSIVE POLYNEUROPATHY

15 Page 15 of OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY ACUTE INFECTIVE POLYNEURITIS POLYNEUROPATHY IN COLLAGEN VASCULAR DISEASE POLYNEUROPATHY IN DIABETES POLYNEUROPATHY IN MALIGNANT DISEASE POLYNEUROPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE ALCOHOLIC POLYNEUROPATHY POLYNEUROPATHY DUE TO DRUGS POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS CHRONIC INFLAMMATORY DEMYELINATING POLYNEURITIS CRITICAL ILLNESS POLYNEUROPATHY OTHER INFLAMMATORY AND TOXIC NEUROPATHY MYASTHENIA GRAVIS WITHOUT (ACUTE) EXACERBATION MYASTHENIA GRAVIS WITH (ACUTE) EXACERBATION MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE TOXIC MYONEURAL DISORDERS OTHER SPECIFIED MYONEURAL DISORDERS MYONEURAL DISORDERS UNSPECIFIED CONGENITAL HEREDITARY MUSCULAR DYSTROPHY HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY MYOTONIC MUSCULAR DYSTROPHY PERIODIC PARALYSIS TOXIC MYOPATHY MYOPATHY IN ENDOCRINE DISEASES CLASSIFIED ELSEWHERE SYMPTOMATIC INFLAMMATORY MYOPATHY IN DISEASES CLASSIFIED ELSEWHERE CRITICAL ILLNESS MYOPATHY OTHER MYOPATHIES MYOPATHY UNSPECIFIED MYOPATHY OF EXTRAOCULAR MUSCLES ESOTROPIA UNSPECIFIED - ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES EXOTROPIA UNSPECIFIED - ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES INTERMITTENT HETEROTROPIA UNSPECIFIED - INTERMITTENT EXOTROPIA ALTERNATING

16 Page 16 of HETEROTROPIA UNSPECIFIED - ACCOMMODATIVE COMPONENT IN ESOTROPIA HETEROPHORIA UNSPECIFIED - ALTERNATING HYPERPHORIA PARALYTIC STRABISMUS UNSPECIFIED - TOTAL OPHTHALMOPLEGIA MECHANICAL STRABISMUS UNSPECIFIED - LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS DUANE'S SYNDROME - STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS PALSY OF CONJUGATE GAZE - OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS UNSPECIFIED DISORDER OF EYE MOVEMENTS ORTHOSTATIC HYPOTENSION LARYNGEAL SPASM ANAL SPASM DERMATOMYOSITIS POLYMYOSITIS EOSINOPHILIA MYALGIA SYNDROME CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY CERVICAL SPONDYLOSIS WITH MYELOPATHY THORACIC SPONDYLOSIS WITHOUT MYELOPATHY LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY SPONDYLOSIS WITH MYELOPATHY THORACIC REGION SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY DISPLACEMENT OF THORACIC INTERVERTEBRAL DISC WITHOUT MYELOPATHY DISPLACEMENT OF INTERVERTEBRAL DISC SITE UNSPECIFIED WITHOUT MYELOPATHY DEGENERATION OF CERVICAL INTERVERTEBRAL DISC DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRAL DISC DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC DEGENERATION OF INTERVERTEBRAL DISC SITE UNSPECIFIED INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY UNSPECIFIED REGION

17 Page 17 of INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY CERVICAL REGION INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY THORACIC REGION INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION POSTLAMINECTOMY SYNDROME OF UNSPECIFIED REGION POSTLAMINECTOMY SYNDROME OF CERVICAL REGION POSTLAMINECTOMY SYNDROME OF THORACIC REGION POSTLAMINECTOMY SYNDROME OF LUMBAR REGION OTHER AND UNSPECIFIED DISC DISORDER OF CERVICAL REGION OTHER AND UNSPECIFIED DISC DISORDER OF THORACIC REGION OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION SPINAL STENOSIS IN CERVICAL REGION BRACHIAL NEURITIS OR RADICULITIS NOS TORTICOLLIS UNSPECIFIED SPINAL STENOSIS OF UNSPECIFIED REGION SPINAL STENOSIS OF THORACIC REGION SPINAL STENOSIS OF LUMBAR REGION SPINAL STENOSIS OF OTHER REGION PAIN IN THORACIC SPINE LUMBAGO SCIATICA THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED BACKACHE UNSPECIFIED INFECTIVE MYOSITIS SPASM OF MUSCLE MUSCLE WEAKNESS (GENERALIZED) UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA NEURALGIA NEURITIS AND RADICULITIS UNSPECIFIED PAIN IN LIMB OTHER MUSCULOSKELETAL SYMPTOMS REFERABLE TO LIMBS WRIST DROP (ACQUIRED) CLAW HAND (ACQUIRED) OTHER ACQUIRED DEFORMITIES OF FOREARM EXCLUDING FINGERS OTHER ACQUIRED DEFORMITIES OF ANKLE AND FOOT

18 Page 18 of TRANSIENT PARALYSIS OF LIMB TETANY DISTURBANCE OF SKIN SENSATION OTHER VOICE DISTURBANCE RETENTION OF URINE UNSPECIFIED INCOMPLETE BLADDER EMPTYING OTHER SPECIFIED RETENTION OF URINE URGE INCONTINENCE URINARY FREQUENCY C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED C1-C4 LEVEL WITH COMPLETE LESION OF SPINAL CORD C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME C1-C4 LEVEL WITH CENTRAL CORD SYNDROME C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY C5-C7 LEVEL SPINAL CORD INJURY UNSPECIFIED C5-C7 LEVEL WITH COMPLETE LESION OF SPINAL CORD C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME C5-C7 LEVEL WITH CENTRAL CORD SYNDROME C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED T1-T6 LEVEL WITH COMPLETE LESION OF SPINAL CORD T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME T1-T6 LEVEL WITH CENTRAL CORD SYNDROME T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY T7-T12 LEVEL SPINAL CORD INJURY UNSPECIFIED T7-T12 LEVEL WITH COMPLETE LESION OF SPINAL CORD T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME T7-T12 LEVEL WITH CENTRAL CORD SYNDROME T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY LUMBAR SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY SACRAL SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY CAUDA EQUINA SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY MULTIPLE SITES OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY UNSPECIFIED SITE OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

19 Page 19 of INJURY TO CERVICAL NERVE ROOT INJURY TO DORSAL NERVE ROOT INJURY TO LUMBAR NERVE ROOT INJURY TO SACRAL NERVE ROOT INJURY TO BRACHIAL PLEXUS INJURY TO LUMBOSACRAL PLEXUS INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS INJURY TO UNSPECIFIED SITE OF NERVE ROOTS AND SPINAL PLEXUS INJURY TO CERVICAL SYMPATHETIC NERVE EXCLUDING SHOULDER AND PELVIC GIRDLES INJURY TO OTHER SYMPATHETIC NERVE EXCLUDING SHOULDER AND PELVIC GIRDLES INJURY TO OTHER SPECIFIED NERVE(S) OF TRUNK EXCLUDING SHOULDER AND PELVIC GIRDLES INJURY TO UNSPECIFIED NERVE OF TRUNK EXCLUDING SHOULDER AND PELVIC GIRDLES INJURY TO AXILLARY NERVE INJURY TO MEDIAN NERVE INJURY TO ULNAR NERVE INJURY TO RADIAL NERVE INJURY TO MUSCULOCUTANEOUS NERVE INJURY TO CUTANEOUS SENSORY NERVE UPPER LIMB INJURY TO DIGITAL NERVE UPPER LIMB INJURY TO OTHER SPECIFIED NERVE(S) OF SHOULDER GIRDLE AND UPPER LIMB INJURY TO MULTIPLE NERVES OF SHOULDER GIRDLE AND UPPER LIMB INJURY TO UNSPECIFIED NERVE OF SHOULDER GIRDLE AND UPPER LIMB INJURY TO SCIATIC NERVE INJURY TO FEMORAL NERVE INJURY TO POSTERIOR TIBIAL NERVE INJURY TO PERONEAL NERVE INJURY TO CUTANEOUS SENSORY NERVE LOWER LIMB INJURY TO OTHER SPECIFIED NERVE(S) OF PELVIC GIRDLE AND LOWER LIMB INJURY TO MULTIPLE NERVES OF PELVIC GIRDLE AND LOWER LIMB

20 Page 20 of INJURY TO UNSPECIFIED NERVE OF PELVIC GIRDLE AND LOWER LIMB INJURY TO SUPERFICIAL NERVES OF HEAD AND NECK INJURY TO OTHER SPECIFIED NERVE(S) INJURY TO MULTIPLE NERVES IN SEVERAL PARTS INJURY TO NERVES UNSPECIFIED SITE Diagnoses that Support Medical Necessity Not applicable ICD-9 Codes that DO NOT Support Medical Necessity Not applicable ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity Not applicable General Information Documentation Requirements The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. The clinical history and examination, carried out before the study, must always describe and document clearly and comprehensibly, the need for the planned test. Documentation should include patient history for sensory and/or motor nerve dysfunction. The patient's medical records must clearly document the medical necessity of the test and the type of test to be performed. It is not necessary to include documentation with each claim submission. Data gathered during NCS, however, should be available. It should reflect the actual numbers (latency, amplitude, etc.), preferably in a tabular (not narrative) format. Credentials of providers billing for needle electromyography must be available on request. The reason for referral and a clear interpretation are required for each study. Hard copies of wave forms obtained should be available. If hard copies are not available, a detailed report may be acceptable.

21 Page 21 of 24 There must be documentation justifying the study. National Government Services recognizes that the provider that ordered the test is often not the person who interprets the test. Diagnostic tests, as EMG and NCS, may have been ordered by a treating clinician, but performed and interpreted by another qualified health care professionals. In situations like this where two separate entities provide patient care, the onus of providing, obtaining and maintaining documentation does not rest in the exclusive domain of one or the other entity. Both the ordering and testing qualified health care professionals have this responsibility. In order to render good patient care and to receive Medicare payment, documentation is a basic prerequisite. Section 4317 of the Balanced Budget Act (BBA: SEC REQUIREMENT TO FURNISH DIAGNOSTIC INFORMATION) addresses this situation: When a test is, "...ordered by a physician or a practitioner specified in subsection (b) (18)(C), but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner." Certain less than optimal practices are discouraged, and may invite reviews. They are: narrative reports alluding to "normal" or "abnormal" results without numerical data; descriptions of F-wave without reference to a corresponding motor conduction data; pattern-setting unilateral H-reflex measurements or separate E/M consultation charges without documentable request from the referral source. When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act. Documentation must be available to Medicare upon request. Appendices Not applicable Utilization Guidelines Excessive use of units of testing (see table immediately below, based on a White Paper prepared by the American Association of Electrodiagnostic Medicine on suggested upper limits for CPT ) will be considered not medically necessary. Consistent repeated testing on the same patient, or testing every patient referred for pain, weakness or paresthesia may become evident on review. In such cases, the claim will considered not medically necessary. The NCS-EMG performing provider, in consultation with the referring provider, is responsible for determination of the appropriateness of a study.

22 Page 22 of 24 Conditions Motor NCV (CPT code 95900) Sensory NCV (CPT code 95904) Carpal Tunnel (unilateral) 3 4 Carpal Tunnel (bilateral) 4 6 Radioculopathy 3 2 Mononeuropathy 3 3 Polyneuropathy 4 4 Myopathy 2 2 ALS 4 2 Plexopathy Neuromuscular junction disorder Testing of the contralateral limb must be supported by medical necessity. Sources of Information and Basis for Decision This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below. AANEM Position Statement, Muscle Nerve 33: , 2006 AANEM Practice Topics, September, 2006 American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) Recommended Policy for Electrodiagnostic Medicine Brown Elizabeth, MD, An Evidence Based Technology Assessment of the NC-stat Device; March 19, 2007 Morse, Josh, NC-stat System, NeuroMetrix Inc. (Nerve Conduction Testing System) Technology Assessment: June 8, Other Contractor Local Coverage Determinations Stalberg, Erdem; Nerve Conduction Studies; The Online Journal of Neurological Sciences: 17 (2), Advisory Committee Meeting Notes Carrier Advisory Committee Meeting Date(s):

23 Page 23 of 24 Indiana 02/04/2008 Kentucky 02/07/2008 New Jersey 02/06/2008 New York 01/30/2008 This coverage determination does not reflect the sole opinion of the contractor or contractor Medical Director. Although the final decision rests with the contractor, this determination was developed in consultation with representatives from Advisory Committee members and/or from various state and local provider organizations. Any Carrier Advisory Committee (CAC) related information, including Start Date and End Date of Comment Period, reflects the last time this LCD passed through the Comment and Notice process. Formal comment is not required for LCDs being adopted as part of the MAC transition. Start Date of Comment Period 01/17/2008 End Date of Comment Period 03/01/2008 Start Date of Notice Period 06/03/2008 Revision History Number R#1 Revision History Explanation R#1: This revised LCD is effective for all National Government Services jurisdictions on July 18, 2008 with these exceptions: for Connecticut Part B the LCD is effective on August 1, 2008; for Upstate New York Part B, the LCD is effective on September 1, 2008; and for New York and Connecticut Part A, the LCD is effective on November 14, For New York Part A (contract 00308), the content of this LCD is currently in effect but the LCD will be transferred to the J-13 contract number on November 14, This LCD was revised during the Notice period of 05/15/ /30/2008 to add the Jurisdiction 13 (J-13) MAC contractor numbers. The CMS Statement of Work for the J13 Medicare Administrative Contract (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This NGS policy is being promulgated to the J13 MAC as the most clinically appropriate LCD within that jurisdiction. The NGS roster of LCDs has been developed under the combined experience of seven Medicare contractor medical directors. The criteria for inclusion in this roster includes areas of identified CERT errors, especially repetitive errors; high volume/high dollar/pervasive problems; patient safety issues; potential for automation; beneficiary access to new technology; implementation of NCD; narrative medical necessity parameters for medical review and provider education; and CMS/law enforcement mandates.

24 Page 24 of 24 NGS LCDs have undergone an advice and comment process from the providers in 23 states. This advice and comment process, the most comprehensive among all Medicare contractors, has ensured that NGS policies have benefited from the most in-depth and scientifically rigorous scrutiny. The NGS policy development process has resulted in the most clinically appropriate LCDs for providers and Medicare beneficiaries. Reason for Change Not applicable Last Reviewed On Date 06/03/2008 Related Documents Article(s) A Nerve Conduction Studies (NCS)/Electromyography (EMG) - Supplemental Instructions Article LCD Attachments NCS - Comment and Response (121,076 bytes) Close