Nerve Conduction Studies and Electromyography

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for nerve conduction studies and electromyography. 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 nerve conduction studies and electromyography and must properly submit only valid claims for them. 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 Covered Medical and Other Health Services, 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 Publication 100-04, Medicare Claims Processing Manual, Chapter 23 Fee Schedule Administration and Coding Requirements

Social Security Act (Title XVIII) Standard References:

• 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.
• 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.

Federal Register References:

• Title 42 Code of Federal Regulations (CFR) Section 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

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

Electromyography (EMG) is the study and recording of intrinsic electrical properties of skeletal muscles. This is carried out with a needle electrode. Generally, the needles are of two types: monopolar or concentric. There is a requirement for ongoing real-time clinical diagnostic evaluation, especially during EMG examination. Also, EMG examination is invasive. Needle placement in the exact muscle of interest is essential. It requires needle exploration near vital structures as the pleura, femoral neurovascular bundle, peritoneum, intraspinal spaces, carotid artery, orbit and brachial plexus. Risk of infection from AIDS, Hepatitis B-E, Creutzfeldt-Jakob encephalopathy, and hemorrhage from anticoagulation can be managed by proper techniques.

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:

1. the myelin sheath (Schwann cell derived insulation covering an axon), and
2. the axon (an extension of neuronal cell body) of a nerve.

Interruption of axon and dysfunction of myelin will both affect NCS results.

EMG is undertaken together with nerve conduction studies (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 the clinical diagnoses being evaluated to decide whether to continue, modify, or conclude a test. This process requires knowledge of anatomy, physiology and neuromuscular diseases.

There may be instances where questions about an indication or need for a study will arise. The clinical history and examination, carried out before the study, must always describe and document clearly and comprehensibly the need for the planned test. A "rule-out" diagnosis is typically not acceptable. The Contractor is cognizant of the fact that patients are not always referred with a definite diagnosis in mind. Often, pain, paresthesia, or weakness in an extremity is the reason for an NCS or EMG. These common symptoms result not only from axonal and myelin dysfunction but also from systemic, non-neurological illnesses. EMG and NCS may help in making this distinction. Therefore, symptom-based diagnoses such as "pain in limb," weakness, disturbance in skin sensation or "paresthesia" are acceptable provided the clinical assessment unequivocally supports the need for a study. To cite but one example of many, an EMG or NCS is irrelevant as a first order diagnostic test for limb pain resulting from immediate antecedent trauma or acute bone injury.

Both EMGs and NCSs are required for a clinical diagnosis of peripheral nervous system disorders. EMG results reflect on the integrity of the functioning connection between a nerve and its innervated muscle and also on the integrity of a muscle itself. Performance of one 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.

The electrodiagnostic evaluation is actually 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 without awareness and ability to diagnose and manage neuromuscular diseases, is not always adequate for electrodiagnostic consultation. Recognition and experience in the management of disparate diseases that produce common electrodiagnostic findings may be necessary. For example, EMG-NCS findings may overlap in the following pairs of disorders: inflammatory myopathies and ALS, ALS and multi-level radiculopathies, myotonia of channelopathies (periodic paralyses) and myotonic dystrophies, focal neuropathies such as Carpal Tunnel Syndrome and proximal plexopathies. Other instances where knowledge of disease behavior is crucial are Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) and Multifocal Motor Neuropathy (MMN). These entities display electrodiagnostic features that resemble generalized polyneuropathies. Neuromuscular transmission disorders require separation based on clinical presentation and electrical features. Treatment will depend on differentiating among them. Without awareness of the disease spectrum, diagnosis solely by EMG-NCS findings may be either wrong or detrimental to the patient.

In summary, axonal and muscle involvement are most sensitively detected by EMGs, and myelin and axonal involvement are best detected by NCSs.

Electromyography (EMG)

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 neurologic conditions in which EMG is potentially helpful, although not an all-inclusive listing, are disc disease producing spinal nerve dysfunction, advanced nerve compression in peripheral lesions, Amyotrophic Lateral Sclerosis (ALS), and polyneuropathy, etc. After an acute neurogenic lesion, it is important to note that EMG changes may not appear for several days to weeks in the innervated muscles.

Primary muscle diseases such as polymyositis will also alter a normal EMG pattern. Myotonic disorders may show a pattern of spontaneous repetitive discharges on needle exploration.

Neurogenic disorders can be distinguishable from myopathic disorders by a carefully performed EMG. For example, both polymyositis and ALS (Amyotrophic Lateral Sclerosis) produce weakness. The former carries a very different prognosis and treatment than the latter. An EMG is very valuable in making this distinction. Similarly, classification of nerve trauma into axonal vs. demyelinating categories, with corresponding differences in prognoses, are possible with EMG. Below is a list of common disorders where an EMG, in tandem with properly conducted NCS, will be helpful in diagnosis:

1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions
2. Radiculopathy - cervical, lumbosacral
3. Mono/polyneuropathy - metabolic, degenerative, hereditary
4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies
5. Plexopathy - idiopathic, trauma, infiltration
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here
7. At times, immediately prior to Botulinum A toxin injection, for localization
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or chemodenervation

There may be other instances, not detailed here, where EMG may be of use.

Use of EMG with Botulinum Toxin Injection

EMG may be used to optimize the anatomic location of botulinum toxin injection. It is expected there will be one study performed per anatomic location of injection, if needed.

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 - This is not the same as a conventional EMG and involves the use of a probe that is passed over the surface of the skin in order to measure electrical muscle activity. This method of EMG testing is considered investigational and is not a covered service. Surface and macro EMGs will be denied as not medically necessary. An exception may be made for the use of surface EMG when used for EMG studies of the anal or urethral sphincter when performed in accordance with LCD L34977 (Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters). See that document for further coverage and limitations.
• multiple uses of EMG in the same patient at the same location of the same limb for the purpose of optimizing botulinum toxin injections

Nerve Conduction Studies (NCS)

The dichotomy into axonal and demyelinating neuropathies provides a practical means of correlating electrical abnormalities with major pathophysiologic changes in the nerve. Electrical studies can be of help in localization of an abnormality and in distinguishing one variety of neuropathy from another: for example, diffuse vs. multifocal; axonal vs. demyelinating. Such distinction has diagnostic value. Specific classification of nerve injuries into neuropraxia and axonotmesis can be made on the basis of conduction studies and electromyography. Such classification has a bearing on prognosis and treatment.

1. Focal neuropathies or compressive lesions such as carpal tunnel syndrome, ulnar neuropathies or root lesions, for localization
2. Traumatic nerve lesions, for diagnosis and prognosis
3. Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic, metabolic or immune
4. Repetitive nerve stimulation in diagnosis of neuromuscular junction disorders such as myasthenia gravis, myasthenic syndrome
5. There may be other instances, not detailed here, where NCS may be of use. Not all possible or potential indications are addressed here

The following definitions are from the American Association of Neuromuscular Electrodiagnostic Medicine Recommended Policy for Electrodiagnostic Medicine.

The stimulation of nerves is similar across all NCSs; the characteristics of motor, sensory, and mixed NCSs are different and are discussed separately below. In each case, an appropriate nerve is stimulated and recording is made either from the appropriate nerves or from muscle supplied by the motor nerve.

1. Motor - Motor NCSs 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.
2. Sensory - Sensory NCSs 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 and configuration.
3. Mixed NCSs 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, configuration, and motor conduction velocity.
4. Nerve conduction studies performed using automated devices (for example devices such as NC-stat® System) cannot support testing of other locations and other nerves as needed depending on the concurrent results of testing. Please refer to the related billing and coding article (A54095) for coding instructions when reporting these services.

When the beneficiary has a high (more than 80%) pre-test or a prior probability for having the diagnosis of Carpal Tunnel Syndrome, the NC-stat® System (alone) will be considered medically reasonable and necessary, for Carpal Tunnel Syndrome. All other diagnoses will be denied as not medically necessary. One service per arm, per beneficiary, per lifetime will be allowed.

Nerve conduction studies performed independent of needle electromyography (EMG) may only provide a portion of the information needed to diagnose muscle, nerve root, and most nerve disorders. When the nerve conduction study (NCS) is used on its own without integrating needle EMG findings, or when an individual relies solely on a review of NCS data, the results can be misleading and important diagnoses may be missed.

In most instances, both NCS and EMG are necessary to perform diagnostic testing. While a provider may choose to perform just a NCS, when performed alone it will be considered to be a screening exam. The only exception to this is a situation where a provider may consider it appropriate to perform a NCS without doing an EMG for the diagnosis of carpal tunnel syndrome with a high pre-test probability that has yet to be confirmed.

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 accomplish this task better than distal NCS. Current evidence in standard peer-reviewed medical journals does not support the use of F waves, in isolation, to diagnose radiculopathy. This is to be contrasted with the investigation of distal peripheral nerves, which is accomplished by nerve conduction studies generally accompanied by EMG.

Screening testing for polyneuropathy of diabetes or end-stage 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 considered to be part of the physical exam and may not be billed as a separate service.

Current Perception Threshold/Sensory Nerve Conduction Threshold Test (sNCT) - Please refer to NCD 160.23 (listed in the IOM Citations at the beginning of the LCD) for coverage information.

Examination using portable hand-held devices, or devices which are incapable of real-time wave-form display and analysis and incapable of both NCS and EMG testing, will be included in the Evaluation and Management (E/M) service. They will not be paid separately. Examples include: The Axon II or delta fiber analysis testing or machines with other names.

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.

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 is covered only once per upper extremity limb per patient per year for a diagnosis of carpal tunnel syndrome.

Place of Services (POS)
EMG/NCS studies will not be covered when provided in the home of the beneficiary.

Provider Qualifications
Guidelines about proper qualifications for qualified health care professionals performing electrodiagnostic evaluations have been developed and published by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) 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 Specialties (ABPTS) in Clinical Electrophysiology, and the Department of Veterans Affairs.

Novitas Solutions, Inc expects healthcare professionals who perform electrodiagnostic (ED) testing will be appropriately trained and/or credentialed, either by a formal residency/fellowship program, certification by a nationally recognized organization or by an accredited post-graduate training course covering anatomy, neurophysiology and forms of electrodiagnostics (including both NCS and EMG) acceptable to this Contractor, in order to provide the proper testing and assessment of the patient's condition and appropriate safety measures. It would be highly unlikely that this training and/or credentialing is possessed by providers other than Neurologists, or Physical Medicine and Rehabilitation physicians.

For outpatient settings other than Comprehensive Outpatient Rehabilitation Facility (CORF), references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants.

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, and all Medicare Payment rules.

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

N/A

N/A

Refer to the Local Coverage Article: Billing and Coding: Nerve Conduction Studies and Electromyography, A54095, for all coding information.

Other Information

Refer to LCD L34977 for information on Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters.

Refer to LCD L34996 for more detailed guidelines on Neuromuscular Junction Testing.

Refer to LCD L35003 for more detailed guidelines on Intraoperative Neurophysiological Testing.

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 the care to the patient.
3. The medical record documentation must support the medical necessity of the services as stated in this policy.
4. Data gathered during NCS, however, should be available which reflect the actual numbers (latency, amplitude, etc.), preferably in a tabular (not narrative) format. The reason for referral and a clear diagnostic impression are required for each study. In cases where a review becomes necessary, either a hard copy of waveforms or a complete written report with an interpretation of the test must be submitted upon request.
5. Normal findings and abnormalities uncovered during the study should be documented with the muscles tested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials and interpretation.

Utilization Guidelines

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

Excessive use of units of testing (see table immediately below, based on a White Paper prepared by the American Association of Electrodiagnostic Medicine) 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 be 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.

Testing of the contralateral limb must be supported by medical necessity.

Consultants in Various Specialties

Other Contractor(s)' Policies

Contractor Medical Directors

Original JH ICD-9 Source LCD L32723, Nerve Conduction Studies and Electromyography

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

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