Billing and Coding: Nerve Conduction Studies and Electromyography

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 of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34859 Nerve Conduction Studies and Electromyography. Please refer to the LCD for reasonable and necessary requirements.

Evaluation/Management (E/M)

• 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.
  

Coding Guidance

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

Nerve Conduction Studies

CPT code 95905 -Nerve conduction studies performed using preconfigured electrode array(s) (i.e., 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 and must not be billed with any CPT code other than CPT code 95905.

When the beneficiary has a high pre-test or a priori probability for having the diagnosis of Carpal Tunnel Syndrome, the automated devices (for example NC-stat® System) alone will be allowed, one service per arm, using CPT code 95905. The diagnosis code G56.00-G56.03 should be used. All other diagnosis codes will be denied.

CPT code 95905 is payable only once per limb studied and cannot be used in conjunction with any other nerve conduction codes.

The table Type of Study/Maximum Number of Studies in Appendix J Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves of the CPT codebook 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.

• 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 should be able to provide supplementary documentation to justify the additional testing.
• 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.
•  Per the CPT code book, “codes 95907-95913 describe one or more nerve conduction studies. For the purpose of coding, a single conduction study 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 nerve includes all orthodromic and antidromic impulses associated with that nerve and constitutes a distinct study when determining the number of studies in each grouping (e.g., 1-2 or 3-4 nerve conduction studies). Each type of nerve conduction study is counted only once when multiple sites on the same nerve are stimulated and recorded. The numbers of these separate tests should be added to determine which code to use.” 

Electromyography

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. It is not expected 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.

Use EMG codes 95860-95864 and 95867-95870 when no nerve conduction studies (95907-95913) are performed on that day.

Use 95885-95887 for EMG services when nerve conduction studies (95907-95913) are performed on the same day.

CPT Code 95869 - Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12):

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 95869 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, limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic, paraspinal, cranial nerve supplied muscles, or sphincters:

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 extremity are tested, and when the extremity codes 95860, 95861, 95863, or 95864 are reported.

CPT Code 95933 – Orbicularis oculi (blink) reflex, by electrodiagnostic testing

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 testing (repetitive stimulation, paired stimuli), each nerve, any 1 method

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 stimulus (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 NCSs of the same nerves and are reimbursed separately.

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 7A). 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 can perform procedures assigned level of 21, 22, 66, 6A, 77, or 7A without supervision. These numeric levels assigned to the CPT codes are listed in the Medicare Physician Fee Schedule Database (MFSDB).

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.

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

The technical component 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 electromyographic (EMG) codes 95860-95870 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 component of the test according to the description of 6A.

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 submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
4. The patient’s medical records must clearly document the medical necessity for the test. It is not necessary to include documentation with each claim submission. 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, a hard copy of waveforms and/or a complete written report with an interpretation of the test, sufficient to evidence the necessity, 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.
6. When requesting an individual consideration through the written redetermination (formerly appeal) process, providers must include all relevant medical records and literature that supports the request. At a minimum two Phase II studies (human feasibility studies suggesting efficacy, pilots) or one Phase III study (primary evidence of safety and efficacy, pivotal) must be submitted for review.