Billing and Coding: Nerve Conduction Studies and Electromyography

CMS National Coverage Policy
Code of Federal Regulations:
42 CFR Section 410.32 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.

Federal Register:
Federal Register Vol. 62, 59047, Supervision of Diagnostic Tests, describes the degree of physician supervision required for diagnostic tests.

CMS Publications:
CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2: 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)

Program Memorandum Carriers Transmittal B-01-28 Change Request 850, describes tests that may be performed by PTs with ABPTS certification CMS Publication 100-2. Medicare Benefit Policy Manual, Chapter 15, Section 80: Requirements for Diagnostic Tests.

Transmittal 2663 Change Request 8169 April Update to the CY 2013 Medicare Physician Fee Schedule Database (MPFSDB).

The following coding and billing guidance is to be used with its associated Local coverage determination.

Physical Therapists Performing EMGs

Program Memorandum Transmittal B-01-28/Change Request 850 sets forth revised levels of physician supervision required for diagnostic tests payable under the Medicare Physician Fee Schedule. Effective July 1, 2001, certain codes in the range of CPT 95860-95937 were assigned new supervision levels (21, 22, 6a, 66, 77 or 77a). This implementation date would make it possible for physical therapists to acquire the certification required to perform these services without supervision. A physical therapist who is presently certified by the American Board of Physical Therapy Specialties (ABPTS) can perform procedures assigned level of 21, 22, 66, 6a, 77, or 77a without supervision. These numeric levels assigned to the CPT codes are listed in the Medicare Physician Fee Schedule Database (MPFSDB). Physical therapists who do not possess the ABPTS certification by July 1, 2001, may continue to furnish those tests that require the certification if they have been furnishing such diagnostic tests prior to May 1, 2001.

Payment will be based on the Medicare Physician Fee Schedule level of supervision designation.

Nerve conduction code 95905 does not have one of the above designations and is therefore not allowed by Physical Therapists.

The technical component (TC) of the neuromuscular junction testing code 95937 had its Physician Supervision of Diagnostic Procedures Indicator changed to “7A.” This change is effective January 1, 2013.

Needle EMG codes 95860-95872 and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law, Physical Therapists are allowed the technical portion of the test according to the description of 6A.

I. Coding Guidelines

A. Evaluation/Management (E/M)
1. Usually an E&M service is included in the exam performed just prior to and during nerve conduction studies and/or electromyography. If the E&M service is a separate and identifiable service, the medical record must document medical necessity and the CPT code must be billed with a modifier 25.
2. The clinical history from the referral source must indicate the need for testing. These medical records containing pertinent clinical information must be provided for review on request. Absolute inclusive or exclusive criteria for performance of a diagnostic test are difficult to enumerate.

B. Nerve Conduction Studies

1. The table below provides a reasonable maximum number of studies per diagnostic category necessary for a physician to arrive at a diagnosis in 90% of patients with that final diagnosis.
2. The appropriate number of studies to be performed is left to the judgment of the physician performing the evaluation; however, in the small number of cases which require testing in excess of the numbers listed in the table, the physician must be able to provide supplementary documentation to justify the additional testing.
3. In some situations it may be necessary to test an asymptomatic contralateral limb to establish normative values for an individual patient. Documentation must support the medical necessity of the additional test.
4. CPT code 95905 -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. CPT code 95905 is payable only once per limb studied and cannot be used in conjunction with any other nerve conduction codes.

When the beneficiary has a high pre-test or a priori probability for having the diagnosis of Carpal Tunnel Syndrome, the NC-stat® System (alone) will be allowed, one service per arm, using CPT code 95905. The diagnosis codes G56.01, G56.02 or G56.03 should be used. All other diagnosis codes will be denied as not medically necessary.

5. Codes 95907-95913 describe one or more nerve conduction studies. A single conduction test is defined as a sensory conduction test, a motor conduction test with or without an F wave test, or an H-reflex test. Each type of study (sensory, motor with or without F wave, H-reflex) for each anatomically distinct and separately named nerve is counted as a distinct study when determining the number of studies billed. Each type of study is counted only once when multiple sites on the same nerve are stimulated and recorded. The number of tests (sensory, motor with or without F wave, H-reflex) per nerve are added to determine the code to be billed.

Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Procedures Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore if authorized by state law, Physical Therapists are allowed the technical portion and professional component of the test according to the description of 7A.

“7A” = “Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.”
“77” = “Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without certification under direct supervision of a physician (TC only; PC always physician)”.
These changes for 7A are effective January 1, 2013.

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 G0255: 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 Determinations Manual, Chapter 1, Section 160.23

Source: Current Procedural Terminology (CPT) 2016

C. Electromyography
1. Use EMG codes 95860-95864 and 95867-95870 when no nerve conduction studies (95907-95913) are performed on that day.
2. Use 95885, 95886, and 95887 for EMG services when nerve conduction studies (95907-95913) are performed on the same day.
3. To bill these codes, extremity muscles innervated by three nerves (for example, radial, ulnar, median, tibial, peroneal, femoral, not sub branches) or four spinal levels must be evaluated; a minimum of five muscles must have been studied.

4. It is expected that providers will use CPT code 95870 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, 95863 or 95864 is also billed.

CPT Code 95869 - Needle electromyography; thoracic paraspinal muscles
1. CPT code 95869 should be used to bill a limited EMG study of specific muscles. Examinations confined to distal muscles only, such as intrinsic foot or hand muscles, will be reimbursed as Code 95869 and not as 95860-95866.
2. Use CPT Code 96869 to study thoracic paraspinal muscles between T3 and T11.
3. One unit can be billed, despite the number of levels studied or whether unilateral or bilateral.

CPT Code 95870 Needle electromyography, other than paraspinal
1. CPT code 95870 is used for limited testing of specific muscles during an examination. This code should be used only when the muscles tested do not fit more appropriately under another CPT code.
2. CPT code 95870 can be billed at one unit per extremity (one limb, arm or leg), when fewer than five muscles are examined.
3. It can also be used for examining non-limb (axial) muscles (e.g., intercostal, abdominal wall, cervical and lumbar paraspinal muscles (unilateral or bilateral) regardless of the number of levels tested. However, it should not be billed when the paraspinal muscles corresponding to an extremity are tested, and when the extremity codes 95860, 95861, 95863, or 95864 are reported.

CPT Code 95933 - Blink Reflexes
1. Recordings should be made bilaterally with both ipsilateral and contralateral stimulation.
2. The report of this study should include the presence or absence of the R1 and R2 components.

CPT Code 95937 - Neuromuscular Junction Studies
1. Repetitive stimulation studies are used to identify and to differentiate disorders of the NMJ. This test consists of recording muscle responses to a series of nerve stimuli (at variable rates), both before, and at various intervals after, exercise or transmission of high-frequency stimuli.
2. These codes may be used in association with motor and sensory NCS of the same nerves and are reimbursed separately.
3. When this study is performed, the physician's report must document characteristics of the test, including the rate of repetition of stimulations, and any significant incremental or decremental response.

II. Reasons for Denial in addition to those stated in LCD
1. Narrative reports alluding to "normal" or “abnormal" results without supporting numerical data.
2. Descriptions of F-wave without reference to corresponding motor conduction data; pattern-setting unilateral H-reflex measurements; separate E/M charges without documentation requested from the referral source.
3. Surface and/or macro EMGs will not be paid.
4. Failure to submit, upon request or when requesting a review, a clinical history indicating the need for testing.
5. Absence of a clinical history, preferably written by the referral source, indicating the need for the test.
6. Absence of documentation to support repeated testing on the same beneficiary.
7. Testing every beneficiary referred for pain.

Needle electromyographic (EMG) codes 95860-95872, and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law Physical Therapists are allowed the technical portion of the test according to the description of 6A. Definitions below:

6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.

66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.

III. Comments
1. Certain less than optimal practices are discouraged, and may invite review. These include: 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 diagnosis of radiculopathies, narrative reports without data, and premature EMG testing after trauma when EMG changes are unlikely to have taken place.
2. There are situations in which EMG and nerve conduction studies can be valuable in a relatively acute situation with or without trauma, even though full-blown EMG changes may not yet have taken place. An example is, to assess the presence of pre-existing injury or disease after trauma or in the evaluation of some non-traumatic conditions, such as suspected Guillain-Barre´ syndrome. The clinical record must distinctly document such a need.
3. Frequency of testing is a difficult issue to answer. Documented clinical justification, rather than an algorithm, should be the determinant in these instances. While this removes any recipe-style limits, it also calls for clear responsible and evidence-based documentation for any repeat study. Such a guideline applies to all studies including those for patients (i) under medical, surgical or rehabilitative treatment, (ii) for neuropathy and (iii) for patients with chronic renal failure and/or dialysis.