Nerve Conduction Velocity (NCV) & Electromyography (EMG) Studies [For the list of services and procedures that need preauthorization, please refer to www.mcs.com.pr Go to Comunicados a Proveedores, and click Cartas Circulares.] Medical Policy: MP-ME-09-09 Original Effective Date: November 5, 2010 Reviewed: Revised: November 06, 2013 This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and, provider s contract, unless specific contract limitations, exclusions or exceptions apply. Please refer to the member s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion, and hospice services apply subject to the aforementioned exceptions. DESCRIPTION Nerve Conduction Velocity Studies (NCV) measures the speed of conduction of impulses through a nerve. The impulses being measured are artificially supplied by a stimulating electrode placed on the skin over the nerve. Electrical activity in the nerve being stimulated is measured by recording electrodes placed on the skin at various distances from the stimulating electrode. The distance between the stimulating and recording electrodes and the time taken for an electrical impulse to travel between the electrodes are used to calculate the nerve conduction velocity. Nerve conduction tests have two parts testing motor and sensory nerve testing. Nerve conduction velocity studies are performed to evaluate and document a variety of sensory and motor neuropathological conditions in patients with a suspected diagnosis of nerve dysfunction. Nerve dysfunction can be manifested in decreased signal amplitude, slowed conduction velocity or increased latency. Proximal and distal nerve segments may be tested separately to help identify and localize the cause of the patient s condition. Additional tests are sometimes used to evaluate the results of treatment. Although the stimulation of nerves is similar with all NCV studies, the characteristics of motor, sensory, and mixed NCS are different. Motor NCV studies are performed by applying electrical stimulation at various points along the course of a motor nerve while recording the electrical response from an appropriate muscle. Response parameters include amplitude, latency, configuration, and motor conduction velocity. Sensory NCV studies are performed by applying electrical stimulation near a nerve and recording the response from a distant site along the nerve. Response parameters include amplitude, latency, configuration, and sensory conduction velocity. Mixed NCV studies are performed by applying electrical stimulation near a nerve containing both motor and sensory fibers (a mixed nerve) and recording from a different location along that nerve that also contains both motor and sensory nerve fibers. Response parameters include amplitude, latency, 1
configuration, and both sensory and motor conduction velocity. Another type of NCV studies is referred to as late response (H-reflex and F-wave testing) and is usually performed on nerves more proximal to the spine. These segments include the first several centimeters of a compound nerve emerging from the spinal cord or brainstem. They are helpful in diagnosing conditions of radiculopathies, plexopathies, polyneuropathies, and proximal mononeuropathies. Late response studies are additional studies complementary to NCV and are performed during the same patient evaluation. Nerve Conduction Velocity Studies (NCV) and Needle electromyography (EMG) are typically performed together, by trained and qualified practitioners. Both NCV and EMG are used for clinical diagnosis of peripheral nervous system disorders. Electromyography (EMG) is the study and recording of Intrinsic Electrical Properties of Skeletal muscles. This testing is invasive because it requires needle insertion and adjustment at multiple sites, and at anatomically critical areas. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits and coverage. INDICATIONS I., (MCS) considers Nerve Conduction Velocity Studies (NCV) medically necessary under the following conditions: 1. Focal neuropathies or compressive lesions such a 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 syndrome. II., (MCS) considers Electromyography (EMG) medically necessary under the following conditions: 1. Nerve Compression Syndromes, including carpal tunnel syndrome and other focal compressions. 2. Radiculophaty-Cervical, Lumbosacral. 2
3. Mononeuropathy/Polyneuropathy-Metabolic, degenerative, hereditary. 4. Plexopathy-idiopathic, trauma, infiltration. 5. Myopathy-including Poly and dermatomyositis, Myotonic and Congenital Myopathies. 6. Neuromuscular Junction disorders-myasthenia Gravis (Single fiber EMG (95872) is of special value here). III., (MCS) will consider Repeated Nerve Conduction Velocity Studies under the following circumstances: 1. Repeating nerve conduction velocity studies should be based on clinical justification and there should be evidence-based documentation for any repeated study. 2. Repeated nerve conduction velocity studies could be seen after an initial diagnosis has been made for the following conditions: a. For a patient with worsening signs and symptoms; b. For new trauma or injury to the affected area; and/or c. For a patient who is being managed medically for a condition and is not showing signs of improvement using current prescribed modalities. 3. Repeated nerve conduction velocity studies should only be performed for conditions that require medical management and meet the coverage criteria listed in this policy. 4. Not more than two electrodiagnostic evaluations per 12-month period are generally accepted for carpal tunnel syndrome, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction disease. 5. Not more than three electrodiagnostic evaluations in a 12-month period are generally accepted for motor neuropathy and plexopathy. IV., (MCS) considers the following to be Experimental and Investigational: 1. Examination/NCV studies using the NC-stat monitor, the Brevio NCS monitor, the Neural-Scan, and other automated devices are considered experimental and investigational. 2. NCV studies are considered experimental and investigational for screening for polyneuropathy of diabetes or end-stage renal disease. CONTRAINDICATIONS/LIMITATIONS 1. Consistent excessive use of units of testing, repeated testing on the same patient, or testing every patient referred for pain, weakness or paresthesia. 3
2. The NCS-EMG performing provider, in addition to the referring provider, is responsible for determination of the appropriateness of the studies. Refer to Appendix A-Frequency of Testing; which includes the maximum of Studies permitted with medical necessity. 3. Electrodiagnostic studies are covered when performed by providers of Neurology and Physiatry services, or other trained providers who have a detailed knowledge of neuromuscular diseases and awareness of the influence of age, temperature, and body height on the results. 4. Electrodiagnostic studies are covered when performed by physicians who have a detailed and specialized knowledge in NCS 1 and EMG 1 Note 1: When practice in Medicare patients; a qualified physician to perform this service/procedure must be properly enrolled in Medicare. 5. The performance of EMG/NCS by non-physicians is governed by the scope of practice defined by their state and the appropriate level of supervision described in the Federal Register. Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty; or If these skills have been acquired as continuing medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States or Puerto Rico, and designated by the American Medical Association (AMA). Codes 95860, 95861, 95863, 95864, 95867, 95868, 95869, and 95870, 95885, 95886, 95887 require level 6a supervision, which means the service must be performed personally by the physician or a Physical therapist who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist AND is permitted to provide the service under state law. Codes 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913 and 95937 require level 7a supervision which means the services must be personally performed by a physician, or by a physical therapist with (ABPTS) certification, or by a physical therapist lacking certification but under the direct supervision of a Physician, or by a technician with a certification under the general supervision of a physician. 6. Segmental testing of a single nerve represents a single study. For example, a test of the ulnar nerve at wrist, forearm, below elbow, above elbow, axilla, and supraclavicular regions represents one test. Similarly, the use of different methods of measuring the conduction in the same nerve, such as orthodromic and antidromic testing, constitutes one study. 7. The number of tests (units of each CPT code) performed should be the minimum needed to establish an accurate diagnosis. On a particular day of testing, the number of tests performed/nerves tested should not exceed the number of tests/nerves indicated in the table Appendix A-Frequency of Testing, and exceptions may result in medical review. 4
8. Categorically, there are general standards accepted for repeat electrodiagnostic testing in certain categories of diseases. Not more than two electrodiagnostic evaluations per 12-month period are generally accepted for carpal tunnel syndrome, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction disease. Not more than three electrodiagnostic evaluations in a 12-month period are generally accepted for motor neuropathy and plexopathy. Therefore, repeat electrodiagnostic testing should not be needed in a 12-month period in the majority of all cases. Documentation should be available to verify the need for repeat testing on any patient. Note 2 : Sensory Nerve Conduction Threshold Test (snct) is not considered medically necessary by MCS. All uses of snct to diagnose sensory neuropathies or radiculopathies are not considered medically necessary. CODING INFORMATION CPT Codes for Nerve Conduction Velocity Studies (NCS) (List may not be all inclusive) CPT Codes DESCRIPTION 95905 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-Wave study when performed, with interpretation and report; 95907 Nerve conduction studies; 1-2 studies 95908 Nerve conduction studies; 3-4 studies 95909 Nerve conduction studies; 5-6 studies 95910 Nerve conduction studies; 7-8 studies 95911 Nerve conduction studies; 9-10 studies 95912 Nerve conduction studies; 11-12 studies 95913 Nerve conduction studies; 13 or more studies 95937 Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method Current Procedural Terminology (CPT ) 2013 American Medical Association: Chicago, IL. CPT Codes for Electromyography (EMG) (List may not be all inclusive) CPT Codes DESCRIPTION 95860 Needle electromyography; one extremity with or without related paraspinal areas 95861 Needle electromyography; two extremities with or without related paraspinal areas 95863 Needle electromyography; three extremities with or without related paraspinal areas 95864 Needle electromyography; Four extremities with or without related paraspinal areas 95867 Needle electromyography; Cranial Nerve supplied Muscle(s), Unilateral 95868 Needle electromyography, Cranial Nerve Supplied Muscles, Bilateral 95869 Needle Electromyography; Thoracic Paraspinal Muscles (Excluding T1 or T2) 95870 Needle Electromyography; Limited study of Muscle in One Extremity or Non-Limb 5
(Axial) Muscles (Unilateral or Bilateral), other than thoracic Paraspinal, cranial nerve supplied muscles, or sphincters 95872 Needle electromyography using single fiber electrode, with quantitative measurement of Jitter, Blocking and/or fiber density, any/all sites of each muscle studied 95885 Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (list separately in addition to code for primary procedure) 95886 Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (list separately in addition to code for primary procedure) 95887 Needle electromyography, non-extremity (Cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (list separately in addition to code for primary procedure) Current Procedural Terminology (CPT ) 2013 American Medical Association: Chicago, IL. ICD-9 CM Diagnosis Codes (List may not be all inclusive) ICD-9 CM CODES 053.13 Post Herpetic Polyneuropathy 072.72 Mumps polyneuropathy 138 Late effects of acute poliomyelitis 192.2 Malignant Neoplasm Of Spinal Cord 192.3 Malignant Neoplasm Of Spinal Meninges DESCRIPTION 198.3 Secondary Malignant Neoplasm Of Brain And Spinal Cord 198.4 Secondary Malignant Neoplasm Of Other Parts Of Nervous System 249.60 Secondary diabetes mellitus with neurological manifestations; not stated as uncontrolled 249.61 Secondary diabetes mellitus with neurological manifestations; uncontrolled 250.60 Diabetes with neurological manifestations; Type II or unspecified type, not stated as uncontrolled 250.61 Diabetes with neurological manifestations; Type I (juvenile type), not stated as uncontrolled 250.62 Diabetes with neurological manifestations; type II or unspecified type, uncontrolled 250.63 Diabetes with neurological manifestations; type I (juvenile type), uncontrolled 265.1 Other And Unspecified Manifestations Of Thiamine Deficiency 269.1 Deficiency Of Other Vitamins 330.2 Cerebral degeneration in generalized lipidoses 6
333.0 Other degenerative diseases of the basal ganglia 333.2 Myoclonus 333.6 Genetic torsion dystonia 333.71 Athetoid cerebral palsy 333.72 Acute dystonia due to drugs 333.79 Other acquired torsion dystonia 333.81 Blepharospasm 333.82 Orofacial dyskinesia 333.83 Spasmodic Torticollis 333.84 Organic writers cramp 333.89 Others Fragments of torsion dystonia 333.90 Unspecified extrapyramidal disease and abnormal movement disorder 333.99 Other extrapyramidal disease and abnormal movement disorder 334.1 Hereditary spastic paraplegia 334.2 Primary cerebellar degeneration 335.0 Werdnig-Hoffmann disease 335.1 Spinal muscular atrophy 335.10 Spinal muscular atrophy, unspecified 335.11 Kugelberg-Welander disease 335.19 Other 335.2 Motor neuron disease 335.20 Amyotropic lateral sclerosis 335.21 Progressive muscular atrophy 335.22 Progressive bulbar palsy 335.23 Pseudobulbar palsy 335.24 Primary lateral sclerosis 335.29 Other 335.8 Other anterior horn cell diseases 335.9 Anterior horn cell disease, unspecified 336.0 Syringomyelia And Syringobulbia 336.1 Vascular myelopathies 336.2 Subacute combined degenerations of spinal cord in diseases classified elsewhere 336.3 Myelopathy in other diseases classified elsewhere 336.8 Other myelopathy 336.9 Unspecified disease of spinal cord 337.00 Idiopathic Peripheral Autonomic Neuropathy, Unspecified 337.01 Carotid Sinus Syndrome 7
337.09 Other Idiopathic Peripheral Autonomic Neuropathy 337.1 Peripheral autonomic neuropathy in disorders classified elsewhere 337.2 Reflex sympathetic dystrophy 337.20 Reflex sympathetic dystrophy, unspecified 337.21 Reflex sympathetic dystrophic of the upper limb 337.22 Reflex sympathetic dystrophy of the lower limb 337.29 Reflex sympathetic dystrophy of other specified site 337.3 Autonomic Dysreflexia 340 Multiple Sclerosis 341 Other demyelinating diseases of central nervous system 341.0 Neuromyelitis optica 341.1 Schilder s disease 341.2 Acute (transverse) myelitis 341.20 Acute (transverse) myelitis NOS 341.21 Acute (transverse) myelitis in conditions 341.22 Idiopathic transverse myelitis 341.8 Other demyelinating diseases of central nervous system 341.9 Demyelinating disease of central nervous system, unspecified 342.00 Flaccid hemiplegia; affecting unspecified side 342.01 Flaccid hemiplegia; affecting dominant side 342.02 Flaccid hemiplegia; affecting nondominant side 342.10 Spastic hemiplegia; affecting unspecified side 342.11 Spastic hemiplegia; affecting dominant side 342.12 Spastic hemiplegia; affecting nondominant side 342.80 Other specified hemiplegia; affecting unspecified side 342.81 Other specified hemiplegia; affecting dominant side 342.82 Other specified hemiplegia; affecting nondominant side 342.90 Hemiplegia, unspecified; affecting unspecified side 342.91 Hemiplegia, unspecified; affecting dominant side 342.92 Hemiplegia, unspecified; affecting no dominant side 343.0 Diplegic 343.1 Hemiplegic 343.2 Quadriplegic 343.3 Monoplegic 343.4 Infantile hemiplegia 343.8 Other specified infantile cerebral palsy 343.9 Infantile cerebral palsy, unspecified 8
344.00 Quadriplegia, unspecified 344.01 C1-C4, complete 344.02 C1-C4, incomplete 344.03 C5-C7, complete 344.04 C5-C7, incomplete 344.09 Other 344.1 Paraplegia 344.2 Diplegia of upper limbs 344.3 Monoplegia of lower limb 344.30 Monoplegia of lower limb; affecting unspecified side 344.31 Monoplegia of lower limb; affecting dominant side 344.32 Monoplegia of lower limb; affecting nondominant side 344.4 Monoplegia of Upper Limb 344.40 Monoplegia of Upper Limb; affecting unspecified side 344.41 Monoplegia of Upper Limb; affecting dominant side 344.42 Monoplegia of Upper Limb; affecting nondominant side 344.5 Unspecified Monoplegia 344.6 Cauda equina syndrome 344.60 Cauda equina syndrome; without mention of neurogenic bladder 344.61 Cauda equina syndrome; with neurogenic bladder 344.8 Other specified paralytic syndromes 344.81 Locked in state 344.89 Other specified paralytic syndrome 344.9 Paralysis, unspecified 345.90 Epilepsy, unspecified; without mention of intractable epilepsy 345.91 Epilepsy, unspecified; with intractable epilepsy pharmacoresistant (pharmacologically resistant); or poorly controlled ; or refractory (medically); or treatment resistant 348.1 Anoxic brain damage 348.4 Compression of brain 349.82 Toxic encephalopathy 350.1 Trigeminal neuralgia 350.2 Atypical face pain 350.8 Other specified trigeminal nerve disorders 350.9 Trigeminal nerve disorder, unspecified 351.0 Bell s Palsy 351.1 Geniculate ganglionitis 351.8 Other Facial Nerve Disorders 9
351.9 Facial nerve disorder, unspecified 352.0 Disorders of Olfatory (1 st ) nerve 352.1 Glossopharyngeal neuralgia 352.2 Other disorders of glossopharyngeal (9 th ) nerve 352.3 Disorders Of Pneumogastric (10 th ) Nerve 352.4 Disorders Of Accessory (11 th ) Nerve 352.5 Disorders Of Hypoglossal (12 th ) Nerve 352.6 Multiple Cranial Nerve Palsies 352.9 Unspecified disorder of cranial nerves 353.0 Brachial Plexus Lesions 353.1 Lumbosacral Plexus Lesions 353.2 Cervical Root Lesions Not Elsewhere Classified 353.3 Thoracic Root Lesions Not Elsewhere Classified 353.4 Lumbosacral Root Lesions Not Elsewhere Classified 353.5 Neuralgic Amyotrophy 353.6 Phantom limb (syndrome) 353.8 Other nerve root and plexus disorders 353.9 Unspecified nerve root and plexus disorder 354.0 Carpal tunnel syndrome (CTS) of the wrist 354.1 Other lesion of median nerve 354.2 Lesion of Ulnar nerve 354.3 Lesion of radial nerve 354.4 Causalgia of upper limb 354.5 Mononeuritis multiplex 354.8 Other mononeuritis of upper limb 354.9 Mononeuritis of upper limb, unspecified 355.0 Lesion of sciatic nerve 355.1 Meralgia paresthetica 355.2 Other lesion of Femoral nerve 355.3 Lesion of lateral popliteal nerve 355.4 Lesion of medial popliteal nerve 355.5 Tarsal tunnel syndrome of the ankle 355.6 Lesion of plantar nerve 355.7 Other mononeuritis of lower limb 355.71 Causalgia of lower limb 355.79 Other mononeuritis of lower limb 355.8 Mononeuritis of lower limb, unspecified 10
355.9 Mononeuritis of unspecified site 356.0 Hereditary peripheral neuropathy 356.1 Peroneal muscular atrophy 356.2 Hereditary sensory neuropathy 356.3 Refsum s disease 356.4 Idiopathic progressive polyneuropathy 356.8 Other specified idiopathic peripheral neuropathy 356.9 Idiopathic Peripheral Neuropathy; Unspecified 357.0 Acute infective polyneuritis 357.1 Polyneuropathy in collagen vascular disease 357.2 Polyneuropathy in diabetes 357.3 Polyneuropathy in malignant disease 357.4 Polyneuropathy in other diseases classified elsewhere 357.5 Alcoholic polyneuropathy 357.6 Polyneuropathy due to drugs 357.7 Polyneuropathy due to other toxic agents 357.8 Other Polyneuropathy 357.81 Chronic inflammatory demyelinating polyneuritis 357.82 Critical illness polyneuropathy 357.89 Other inflammatory and toxic neuropathy 357.9 Unspecified neuropathy 358.0 Myasthenia gravis 358.00 Myasthenia gravis without (acute) exacerbation 358.01 Myasthenia gravis with acute exacerbation 358.1 * Myasthenic syndromes in diseases classified elsewhere 358.2 Toxic myoneural disorders 358.3 Lambert-Eaton syndrome 358.30 Lambert-Eaton syndrome, unspecified 358.31 Lambert-Eaton syndrome in neoplastic disease 358.39 Lambert-Eaton syndrome in other diseases classified elsewhere 358.8 Other specified myoneural disorders 358.9 Myoneural disorders, unspecified 359.0 Congenital hereditary muscular dystrophy 359.1 Hereditary progressive muscular dystrophy 359.21 Myotonic muscular dystrophy 359.22 Myotonia congenita 359.23 Myotonic chondrodystrophy 11
359.24 Drug-induced myotonia 359.29 Other specified myotonic disorder 359.3 Periodic paralysis 359.4 Toxic Myopathy 359.5 Myopathy in endocrine diseases classified elsewhere 359.6 Symptomatic inflammatory myopathy in diseases classified elsewhere 359.81 Critical illness myopathy 359.89 Other myopathies 359.9 Unspecified myopathy 368.2 Diplopia 374.30 Ptosis of eyelid, unspecified 374.31 Paralytic ptosis 374.32 Myogenic ptosis 374.33 Mechanical ptosis 374.34 Blepharochalasis 378.0 Esotropia 378.00 Esotropia, unspecified 378.01 Monocular esotropia 378.02 Monocular esotropia with A pattern 378.03 Monocular esotropia with V pattern 378.04 Monocular esotropia with other noncomitancies 378.05 Alternating esotropia 378.06 Alternating esotropia with A pattern 378.07 Alternating esotropia with V pattern 378.08 Alternating esotropia with other noncomitancies 378.1 Exotropia 378.10 Exotropia, unspecified 378.11 Monocular exotropia 378.12 Monocular exotropia with A Pattern 378.13 Monocular exotropia with V Pattern 378.14 Monocular exotropia with other noncomitancies 378.15 Alternating exotropia 378.16 Alternating exotropia with A Pattern 378.17 Alternating exotropia with V Pattern 378.18 Alternating exotropia with other noncomitancies 378.2 Intermittent heterotropia 378.20 Intermittent heterotropia, unspecified 12
378.21 Intermittent esotropia, monocular 378.22 Intermittent esotropia, alternating 378.23 Intermittent exotropia, monocular 378.24 Intermittent exotropia, alternating 378.3 Other and unspecified heterotropia 378.30 Heterotropia, unspecified 378.31 Hypertropia, unspecified 378.32 Hypotropia 378.33 Cyclotropia 378.34 Monofixation syndrome 378.35 Accommodative component in esotropia 378.4 Heterophoria 378.40 Heterophoria, unspecified 378.41 Esophoria 378.42 Exophoria 378.43 Vertical heterophoria 378.44 Cyclophoria 378.45 Alternating hyperphoria 378.5 Paralytic strabismus 378.50 Paralytic strabismus, unspecified 378.51 Third or oculomotor nerve palsy, partial 378.52 Third or oculomotor nerve palsy, total 378.53 Fourth or trochlear nerve palsy 378.54 Sixth or abducens nerve palsy 378.55 External ophthalmoplegia 378.56 Total ophthalmoplegia 378.6 Mechanical strabismus 378.60 Mechanical strabismus, unspecified 378.61 Brown s (tendon) sheath syndrome 378.62 Mechanical strabismus from other musculofascial disorders 378.63 Limited duction associated with other conditions 378.7 Other specified strabismus 378.71 Duane s syndrome 378.72 Progressive external ophthalmoplegia 378.73 Strabismus in other neuromuscular disorders 378.8 Other disorders of binocular eye movements 378.81 Palsy of conjugate gaze 13
378.82 Spasm of conjugate gaze 378.83 Convergence insufficiency or palsy 378.84 Convergence excess or spasm 378.85 Anomalies of divergence 378.86 Internuclear ophthalmoplegia 378.87 Other dissociated deviation of eye movements 378.9 Unspecified disorder of eye movements 384.20 Perforated tympanic membrane, NOS 384.21 Central perforation of tympanic membrane 385.30 Cholesteatoma, unspecified 385.31 Cholesteatoma of attic 385.32 Cholesteatoma of middle ear 385.33 Cholesteatoma of middle ear and mastoid 385.35 Diffuse cholesteatosis 434.00 Cerebral thrombosis; without mention of cerebral infarction 434.01 Cerebral thrombosis; with cerebral infarction 434.10 Cerebral embolism; without mention of cerebral infarction 434.11 Cerebral embolism; with cerebral infarction 434.90 Cerebral artery occlusion, unspecified; without mention of cerebral infarction 434.91 Cerebral artery occlusion, unspecified; with cerebral infarction 438.30 Monoplegia of Upper limb affecting unspecified side 438.31 Monoplegia of Upper limb affecting dominant side 438.32 Monoplegia of Upper 438.40 Monoplegia of lower limb affecting unspecified side 438.41 Monoplegia of lower limb affecting dominant side 438.42 Monoplegia of lower limb affecting nondominant side 478.30 Paralysis, unspecified 478.31 Unilateral, partial 478.32 Unilateral, complete 478.33 Bilateral, partial 478.34 Bilateral, complete 478.75 Laryngeal spasms 478.79 Other diseases of Larynx 596.51 Hypertonicity of bladder 596.54 Neurogenic bladder, NOS 625.6 Stress incontinence, female 646.40 Unspecified as to episode of care or not applicable 14
646.41 Delivered, with or without mention of antepartum condition 646.42 Delivered, with mention of postpartum complication 646.43 Antepartum condition or complication 646.44 Postpartum condition or complication 710.3 Dermatomyositis 710.4 Polymyositis 715.90 Osteoarthritis, unspecified whether generalized or localized; site unspecified 715.91 Osteoarthritis, unspecified whether generalized or localized; Shoulder region 715.92 Osteoarthritis, unspecified whether generalized or localized; Upper arm 715.93 Osteoarthritis, unspecified whether generalized or localized; forearm 715.94 Osteoarthritis, unspecified whether generalized or localized; hand 715.95 Osteoarthritis, unspecified whether generalized or localized; Pelvic region and thigh 715.96 Osteoarthritis, unspecified whether generalized or localized; Lower leg 715.97 Osteoarthritis, unspecified whether generalized or localized; Ankle and foot 715.98 Osteoarthritis, unspecified whether generalized or localized; Other specified sites 717.9 Unspecified internal derrangement of knee 719.40 Pain in joint; Site unspecified 719.41 Pain in joint; Shoulder region 719.42 Pain in joint; Upper arm 719.43 Pain in joint; Forearm 719.44 Pain in joint; hand 719.45 Pain in joint; Pelvic region and thigh 719.46 Pain in joint; Lower leg 719.47 Pain in joint; Ankle and foot 719.48 Pain in joint; Other specified sites 719.49 Pain in joint; Multiples 721.0 Cervical spondylosis without myelopathy 721.1 Cervical spondylosis with myelopathy 721.2 Thoracic spondylosis without myelopathy 721.3 Lumbosacral spondylosis without myelopathy 721.4 Thoracic or Lumbar spondylosis with myelopathy 721.41 Thoracic or Lumbar spondylosis with myelopathy; Thoracic region 721.42 Thoracic or Lumbar spondylosis with myelopathy; Lumbar region 721.5 Kissing spine 721.6 Ankylosing vertebral hyperostosis 721.7 Traumatic spondylopathy 721.8 Other allied disorders of spine 15
721.9 Spondylosis of unspecified site 721.90 Spondylosis of unspecified site; without mention of myelopathy 721.91 Spondylosis of unspecified site; with myelopathy 722.0 Displacement of cervical intervertebral disc without myelopathy 722.1 Displacement of thoracic or lumbar intervertebral disc without myelopathy 722.10 Displacement of Lumbar intervertebral disc without myelopathy 722.11 Displacement of Thoracic intervertebral disc without myelopathy 722.2 Displacement of intervertebral disc, site unspecified, without myelopathy 722.4 Degeneration Of Cervical Intervertebral Disc 722.5 Degeneration of thoracic or lumbar intervertebral disc 722.51 Degeneration of thoracic or thoracolumbar intervertebral disc 722.52 Degeneration of Lumbar or lumbosacral intervertebral disc 722.6 Degeneration of intervertebral disc, site unspecified 722.70 Intervertebral disc disorder with myelopathy; Unspecified region 722.71 Intervertebral disc disorder with myelopathy; Cervical region 722.72 Intervertebral disc disorder with myelopathy; Thoracic region 722.73 Intervertebral disc disorder with myelopathy; Lumbar region 722.80 Post laminectomy Syndrome; Unspecified region 722.81 Post laminectomy Syndrome; Cervical region 722.82 Post laminectomy Syndrome; Thoracic region 722.83 Post laminectomy Syndrome; Lumbar region 722.90 Other and unspecified disc disorder; Unspecified region 722.91 Other and unspecified disc disorder; Cervical region 722.92 Other and unspecified disc disorder; Thoracic region 722.93 Other and unspecified disc disorder; Lumbar region 723.0 Spinal stenosis in cervical region 723.1 Cervicalgia 723.4 Brachial Neuritis or Radiculitis NOS 723.5 Torticollis, unspecified 723.9 Unspecified musculoskeletal disorders and symptoms referable to neck 724.00 Spinal stenosis, unspecified region 724.01 Spinal stenosis of thoracic region 724.03 Spinal stenosis of lumbar region, with neurogenic claudication 724.09 Spinal stenosis, other region other than cervical 724.1 Pain in thoracic spine 724.2 Lumbago 724.3 Sciatica 16
724.4 Thoracic or Lumbosacral Neuritis or Radiculitis, unspecified 724.5 Unspecified backache 724.6 Disorders of sacrum 725 Polymyalgia rheumatica 726.2 Other affections of shoulder region, not elsewhere classified 728.0 Infective myositis 728.2 Muscular Wasting And Disuse Atrophy not elsewhere classified 728.85 Spasm Of Muscle 728.87 Muscle Weakness (Generalized) 728.9 Unspecified disorder of muscle, ligament, and fascia 729.0 Rheumatism, unspecified and fibrositis 729.1 Myalgia and myositis, unspecified 729.2 Neuralgia, neuritis, and radiculitis, unspecified 729.4 Fasciitis, unspecified 729.5 Pain In Limb 729.71 Nontraumatic Compartment Syndrome Of Upper Extremity 729.72 Nontraumatic Compartment Syndrome Of Lower Extremity 729.82 Cramp of Limb 729.89 Other musculoskeletal symptoms referable to limbs 736.05 Wrist Drop (acquired) 736.06 Claw hand (acquired) 736.09 Other acquirer deformities of forearm, excluding fingers 736.79 Other acquired deformities of ankle and foot 737.30 Scoliosis (and kyphoscoliosis), idiopathic 738.4 Acquired spondylolisthesis 747.81 Anomalies of cerebrovascular system 747.82 Spinal vessel anomaly 747.83 Persistent fetal circulation 747.89 Other 756.11 Congenital spondylolysis, lumbosacral region 756.12 Congenital spondylolisthesis 767.4 Injury to spine and spinal cord 767.5 Facial nerve injury 767.6 Injury to brachial plexus 767.7 Other cranial and peripheral nerve injuries 780.79 Other Malaise And Fatigue 781.2 Abnormality of gait 17
781.3 Lack of Coordination 781.4 Transient Paralysis of Limb 781.6 Meningismus 781.7 Tetany 781.93 Ocular torticollis 781.99 Other symptoms involving nervous and musculoskeletal systems 782.0 Disturbance Of Skin Sensation 784.40 Voice and resonance disorder, unspecified 784.42 Dysphonia 784.49 Other voice and resonance disorders 784.51 Dysarthria 784.59 Other speech disturbance 787.20 Dysphagia, unspecified 787.21 Dysphagia, oral phase 787.22 Dysphagia, oropharyngeal phase 787.23 Dysphagia, pharyngeal phase 787.24 Dysphagia, pharingoesophageal phase 787.29 Other Dysphagia 787.60 Full Incontinence of Feces 787.61 Incomplete defecation 787.62 Fecal smearing 787.63 Fecal urgency 788.21 Incontinence bladder emptying 788.30 Urinary incontinence, unspecified 788.31 Urge incontinence 788.32 Stress incontinence, male 788.33 Mixed incontinence (Female)(Male) 788.34 Incontinence without sensory awareness 788.35 Post-void dribbling 788.36 Nocturnal enuresis 788.37 Continuous leakage 788.38 Overflow incontinence 788.39 Other urinary incontinence 796.1 Abnormal reflex 951.0 Injury to oculomotor nerve 951.1 Injury to trochlear nerve 951.2 Injury to trigeminal nerve 18
951.3 Injury to abducens nerve 951.4 Injury to facial nerve 951.5 Injury to acoustic nerve 951.6 Injury to accessory nerve 951.7 Injury to hypoglossal nerve 951.8 Injury to other specified cranial nerves 951.9 Injury to unspecified cranial nerve 952.00 C1-C4 level with unspecified spinal cord injury 952.01 C1-C4 level with complete lesion of spinal cord 952.02 C1-C4 level with anterior cord syndrome 952.03 C1-C4 level with central cord syndrome 952.04 C1-C4 level with other specified spinal cord injury 952.05 C5-C7 level with unspecified spinal cord injury 952.06 C5-C7 level with complete lesion of spinal cord 952.07 C5-C7 level with anterior cord syndrome 952.08 C5-C7 level with central cord syndrome 952.09 C5-C7 level with other specified spinal cord injury 952.10 T1-T6 level with unspecified spinal cord injury 952.11 T1-T6 level with complete lesion of spinal cord 952.12 T1-T6 level with anterior cord syndrome 952.13 T1-T6 level with central cord syndrome 952.14 T1-T6 level with other specified spinal cord injury 952.15 T7-T12 level with unspecified spinal cord injury 952.16 T7-T12 level with complete lesion of spinal cord 952.17 T7-T12 level with anterior cord syndrome 952.18 T7-T12 level with central cord syndrome 952.19 T7-T12 level with other specified spinal cord injury 952.2 Lumbar Spinal Cord Injury Without Spinal Bone Injury 952.3 Sacral Spinal Cord Injury Without Spinal Bone Injury 952.4 Cauda Equina Spinal Cord Injury Without Spinal Bone Injury 952.8 Multiple Sites Of Spinal Cord Injury Without Spinal Bone Injury 953.0 Injury to nerve root and spinal plexus; Cervical root 953.1 Injury to nerve root and spinal plexus; Dorsal root 953.2 Injury to nerve root and spinal plexus; Lumbar root 953.3 Injury to nerve root and spinal plexus; Sacral root 953.4 Injury to nerve root and spinal plexus; Brachial plexus 953.5 Injury to nerve root and spinal plexus; Lumbosacral plexus 19
953.8 Injury to nerve root and spinal plexus; Multiple sites 953.9 Injury to nerve root and spinal plexus; Unspecified site 954.0 Cervical sympathetic 954.1 Other sympathetic 954.8 Other specified nerve(s) of trunk 954.9 Unspecified nerve of trunk 955.0 Axillary nerve 955.1 Median nerve 955.2 Ulnar nerve 955.3 Radial nerve 955.4 Musculocutaneous nerve 955.5 Cutaneous sensory nerve, upper limb 955.6 Digital nerve 955.7 Other specified nerve(s) of shoulder girdle and upper limb 955.8 Multiple nerves of shoulder girdle and Upper limb 955.9 Unspecified nerve of shoulder girdle and upper limb 956.0 Sciatica nerve 956.1 Femoral nerve 956.2 Posterior tibial nerve 956.3 Peroneal nerve 956.4 Cutaneous sensory nerve, lower limb 956.5 Other specified nerve(s) of pelvic girdle and lower limb 956.8 Multiple nerves of pelvic girdle and lower limb 956.9 Unspecified nerve of pelvic girdle and lower limb 957.0 Superficial nerves of head and neck 957.1 Other specified nerve(s) 957.8 Multiple nerves in several parts 957.9 Unspecified site 2014 ICD-9-CM For Physicians, VOLUMES I & II, Professional Edition (American Medical Association) *Note 3: According to the ICD-9-CM Manual, diagnosis code 358.1 is a manifestation code and not allowed to be reported as a primary diagnosis code. HCPCS CODES NOT COVERED (List may not be all inclusive) HCPCS CODES DESCRIPTION G0255 Current Perception Threshold/Sensory Nerve Conduction Test,(Snct) Per Limb, Any Nerve 2013 HCPCS LEVEL II Professional Edition (American Medical Association). 20
REFERENCES 1. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), Proper Performance and Interpretation of Electrodiagnostic Studies. September 2005. Accessed October 21/2013. Available at URL Address: http://www.aanem.org/getmedia/9b4fa3d5-c127-4c3d-9296- b650e443b2cc/properperformance.pdf.aspx 2. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), Recommended Policy for Electrodiagnostic Medicine. Endorsed by the American Academy of Neurology. The American Academy of Physical Medicine and Rehabilitation and the American Association of Neuromuscular and Electrodiagnostic Medicine. Approved by (AANE, AAN, AAPR, 2004). Update 12-31, 2011. Accessed October 21/2013. Available at URL address: http://www.aanem.org/getmedia/93f75546-345e-42d2-bde2-7c838d09d38d/recommended_policy_edx_medicine_1.pdf.aspx 3. American Association of Neuromuscular and Electrodiagnostic Medicine (AAEM), who is qualified to practice electrodiagnostic medicine. Position statement. Approved May 1999. Accessed October 21/2013. Available at URL Address: http://www.northlakeneurology.com/files/qualified.pdf 4. First Coast Service Options, Inc. LCD for Electromyography and Nerve Conduction Studies (L29325). Determination Effective Date: 03/02/2009. Last review 01/01/2013. Accessed October 21/2013. Available at URL Address: http://www.cms.gov/medicare-coveragedatabase/details/lcddetails.aspx?lcdid=29325&contrid=198&ver=13&contrver=1&cntrctrselected=198*1&cntrctr= 198&name=First+Coast+Service+Options%2c+Inc.+(09202%2c+MAC+- +Part+B)&s=46&DocType=Active&bc=AggAAAIAAAAAAA%3d%3d& 5. NCS System. NeuroMetrix. Nerve Conduction on Studies. 2008. Updated 2011. Document not found. Available at URL Address: not available. 6. Point of Care Nerve Conduction Tests for Detecting Nerve Dysfunction. Published: December 2012. Accessed Nov 06/2013. Available at URL Address: https://members2.ecri.org/components/hotline/documents/issuefiles/7354.pdf 21
POLICY HISTORY DATE ACTION COMMENT November 5, 2009 Origination of Policy November 5, 2010 Yearly Review Added code 95905 November 2, 2011 Yearly Review November 8, 2012 Yearly Review References updated. February 21, 2013 Updated Review Policy was reviewed according to LCD (L29325); effective 01/01/2013. Contraindications/ limitations were reviewed for CPTs changes. References were updated. All CPTs, ICD9, and HCPCS Sections were updated. Appendix A Table was reviewed (New codes CPTs changes 2013) Nov 06, 2013 Yearly Review References updated. This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member s plan in effect as of the date services are rendered., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion. Medical Card System, Inc (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide. 22
APPENDIX A-Frequency of Testing The following table lists the American Association of Neuromuscular & Electrodiagnostic Medicine's (formerly known as American Association of Electrodiagnostic Medicine) recommendations concerning a reasonable maximum number of NCV studies, needle EMG and other EMG studies per diagnostic category needed for a physician to render a diagnosis. Each number in the Maximum Number of Studies Table represents 1 study or Unit. Indications Table : Maximum Number of Studies Needle Electromyography, (CPT 95860-95864 and 95867-95870, 95885-95887.) Number of Services (Tests) Nerve Conduction Studies (CPT 95907-95913) Motor NCS with And/or without F wave Sensory NCS Other Electromyographic Studies- CPT 95937 H- Reflex Neuromuscul ar Junction Testing (Repetitive Stimulation) Carpal Tunnel (Unilateral) 1 3 4 - - Carpal Tunnel (Bilateral) 2 4 6 - - Radiculopathy 2 3 2 2 - Mononeurophathy 1 3 3 2 - Polyneuropathy/Mononeuropathy Multiplex 3 4 4 2 - Myopathy 2 2 2-2 Motor Neuronopathy (e.g., ALS) 4 4 2-2 Plexopathy 2 4 6 2 - Neuromuscular Junction 2 2 2 3 Tarsal Tunnel Syndrome (Unilateral) 1 4 4 - - Tarsal Tunnel Syndrome (Bilateral) 2 5 6 - - Weakness, Fatigue, Cramps, or Twitching (focal) Weakness, Fatigue, Cramps, or Twitching (General) Pain, Numbness, or Tingling (Unilateral) Pain, Numbness, or Tingling (Bilateral) 2 3 4-2 4 4 4 2 1 3 4 2-2 4 6 2-23