Neuromuscular Junction Testing

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for neuromuscular junction testing. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for neuromuscular junction testing. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

IOM Citations:

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
• CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)
• CMS IOM 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
• Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
• Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Federal Register References:

• 42 CFR Section 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

Neuromuscular junction testing involves the stimulation of an individual motor nerve by means of repetitive electrical impulses with measurement of the resulting electrical activity of a muscle supplied by that nerve. Supramaximal electrical stimuli are delivered to the nerve. A surface electrode over, or a percutaneous electrode placed in a corresponding muscle, records the evoked muscle action potentials using standard nerve conduction study techniques. The nerve is then stimulated electrically in a repetitive train at 2-3 Hertz (Hz), or in special circumstances at higher rates up to 50 Hz. In diseases of the neuromuscular junction, characteristic changes of a progressive decrease (decrement) in the compound action potential amplitude may be seen during the repetitive stimulation.

Covered Indications

Neuromuscular junction testing by repetitive stimulation may be reasonable and necessary to diagnose patients with fatigable weakness who are being evaluated for possible disease of the neuromuscular junction. These diseases may include myasthenia gravis or Lambert Eaton myasthenic syndrome (LEMS), as well as botulinum toxicity. Rarely, exposure to certain drugs such as aminoglycoside antibiotics or D-Penicillamine can potentiate myasthenic symptoms. Patients in intensive care unit (ICU) settings who experience continued weakness after a critical illness which has required paralyzation for mechanical ventilation may also be candidates for this type of testing.

Limitations

Neuromuscular junction testing by repetitive motor nerve stimulation is not considered reasonable or necessary for indications other than those listed above.

Examples of tests or procedures not covered under repetitive nerve stimulation services include quantitative sensory testing by any means and sensory nerve conduction threshold testing. Tests depending on the patient’s subjective response to single or repetitive stimulation (electrical, vibratory, thermal or tactile), regardless of whether or not these data are analyzed and presented through electronic or computerized systems, also fail to satisfy the definition of neuromuscular junction testing (repetitive stimulation, paired stimuli) each nerve, any one method. 

NOTE: Quantitative sensory testing (QST) uses electrical or mechanical stimuli at varying amplitudes to evoke patients’ subjective responses. Such tests are designed to be helpful in characterizing various types and degrees of neural damage or impairment. However, the clinical usefulness of such tests remains unclear. One such device is the Current Perception Threshold/Sensory Nerve Conduction Threshold test (CPT/sNCT). CMS has determined that this test is not covered since there is insufficient scientific or clinical evidence to consider this device as reasonable and necessary within the meaning of 1862(a)(1)(A) of the Social Security Act. (See also CMS Publication 100-03, Medicare National Coverage Determinations [NCD] Manual, Chapter 1, Part 2, Section 160.23).  Another such device is the pressure-specified sensory device (PSSD), which relies on a pressure stimulus to determine a sensory threshold. 

Neuromuscular junction testing by repetitive stimulation is considered not reasonable and necessary for the diagnosis or treatment of diabetic neuropathy.

Neuromuscular junction testing by repetitive stimulation is considered not reasonable and necessary for the diagnosis or treatment of carpal or tarsal tunnel syndrome.

Neuromuscular junction testing by repetitive stimulation may be reasonable and necessary for certain physical signs and symptoms (e.g., diplopia, dysphagia, weakness, fatigue) only when the medical record indicates that such signs and symptoms are suspected to be caused by a neuromuscular junction disorder.

This LCD imposes frequency limitations. For frequency limitations please refer to the Utilization Guidelines section below.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. Refer to Billing and Coding: Neuromuscular Junction Testing, A56785, for applicable CPT/HCPCS codes and diagnosis codes.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.

N/A

N/A

Refer to Local Coverage Article: Billing and Coding: Neuromuscular Junction Testing, A56785, for all coding information.

Documentation Requirements

1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing care to the patient.
3. The medical record documentation must support the medical necessity of the services as stated in this policy.
4. Medical record documentation for neuromuscular junction testing by repetitive stimulation must indicate the medical necessity for the test and should include a history and physical (including neurologic history and examination) and office/progress notes.
5. Test results for each nerve tested must include the following:
   
   • characteristic of the test,
   • site(s),
   • nerve(s) tested,
   • rate of repetition of stimulations,
   • any significant incremental or decremental response for each, and
   • clinical interpretation of the results.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Proper diagnostic technique generally requires the testing of two distinct nerves/muscle groups.

Testing for more than three nerve/muscle groups per session and more than one session of testing per 180 days will be denied as not medically necessary.

A nerve will be considered an anatomically named nerve.

Baseline and provocative tests performed on distinct nerves/muscle groups whether in the same or different sessions will be considered one test on a distinct nerve or muscle group.

Contractor is not responsible for the continued viability of websites listed.

Other Contractor(s)' Policies

Original JH ICD-9 Source LCD L33650, Neuromuscular Junction Testing

Contractor Medical Directors

1. American Association of Neuromuscular & Electrodiagnostic Medicine, American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation: Recommended policy for electrodiagnostic medicine. http://www.aan.com/globals/axon/assets/4061.pdf.
2. Conti-Fine BM, Milani M, Kaminski HJ. Myasthenia gravis: past, present, and future. J Clin Invest 2006;116:2843–2854.
3. Hill M. The Neuromuscular Junction Disorders. J Neurol Neurosurg Psychiatry 2003 Jun;74(Suppl II):II32-II37.
4. Zivkovic SA, Shipe C. Use of repetitive nerve stimulation in the evaluation of neuromuscular junction disorders. Am J Electroneurodiagnostic Technol 2005 Dec;45(4):248-61.