NCSs measure action potentials recorded over the nerve or from an innervated muscle. Nerve Conduction Velocity (NCV), one aspect of NCS, is measured between two sites of stimulation or between a stimulus and a recording site. It is axiomatic that neurodiagnostic studies are an extension of the history and physical examination of the patient and must be performed as part of a face-to-face encounter. Obtaining and interpreting nerve conduction velocities requires extensive interaction between the performing physician and patient and is most effective when both obtaining raw data and interpretation are performed together on a real-time basis.
Results of NCV 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 the neuronal cell body) of a nerve. Axonal damage or dysfunction generally results in loss of nerve or muscle potential amplitude, whereas demyelination leads to prolongation of conduction time.
The following are examples of appropriate clinical settings where nerve conduction studies are helpful in diagnosing:
- Focal neuropathies or compressive lesions such as carpal tunnel syndrome, ulnar neuropathies or root lesions for localization.
- Traumatic nerve lesions for diagnosis and prognosis.
- Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic, metabolic, inflammatory or immune.
- Repetitive nerve stimulation in diagnosis of neuromuscular junction disorders such as myasthenia gravis and myasthenic syndromes.
The number of sites tested per study depends upon the conditions being evaluated. Generally, the following diagnoses may be established without exceeding the unit limits, which follow:
|
Conditions
|
Motor NCV 95900
|
Sensory NCV 95904
|
F-Wave Study(ies) 95903
|
H-Reflex Study(ies) 95934 & 95936
|
|
Carpal tunnel – Unilateral
354.0
|
3
|
3
|
Documentation of medical necessity required
|
Documentation of medical necessity required
|
|
Carpal tunnel – Bilateral
354.0
|
4
|
4
|
Documentation of medical necessity required
|
Documentation of medical necessity required
|
|
Hemiplegia
342.00–342.02
342.10–342.12
342.80–342.82
342.90–342.92
|
Rarely requires electrodiagnostic testing
|
Rarely requires electrodiagnostic testing
|
Rarely requires electrodiagnostic testing
|
Rarely requires electro-diagnostic testing
|
|
Radiculopathy (i.e., sciatica)
724.00–724.03
724.09
724.1
724.3–724.4
|
3
|
2
|
2
Note: Applies to codes 724.3–724.4 only. Codes 724.00–724.03, 724.09 and 724.1 do not apply to 95903.
|
2
Note: Applies to codes 724.3–724.4 only. Codes 724.00–724.03, 724.09 and 724.1 do not apply to95934 and 95936.
|
|
Mono/poly-neuropathy
356.0–356.4
356.8–356.9
357.0–357.7
357.81–357.82
357.89
357.9
Note: Code 357.9 is listed under limited coverage for CPT codes 95903, 95934 and 95936 only.
|
4
|
4
|
2
|
|
|
Myopathy
359.81
359.89
359.9
|
2
|
2
|
Late wave studies usually not indicated
|
|
|
ALS
335.20–335.24
|
4
|
4
|
Late wave studies usually not indicated
|
|
|
Plexopathy
353.0–353.6
353.8–353.9
|
4–6
|
4–6
|
One study per extremity tested
|
|
|
Neuromuscular junction disorder
358.00–358.01
358.1–358.2
358.8–358.9
|
2
|
2
|
Documentation of medical necessity required
|
Documentation of medical necessity required
|
F-wave studies are often performed in conjunction with motor NCS; H-reflex studies involve both sensory and motor nerves and their connections with the spinal cord. The device used must be capable of recording amplitude, duration, response configuration (motor NCV) and latency and sensory nerve action potential amplitudes (sensory NCV).
Electromyography (EMG) is the study of intrinsic electrical properties of skeletal muscle utilizing insertion of a (frequently disposable) needle electrode into muscles of interest. EMG testing relies on both auditory and visual feedback from the electromyographer. EMG results reflect not only the integrity of the functioning connection between a nerve and its innervated muscle, but on the integrity of the muscle itself. The device used must be capable of recording motor unit recruitment, amplitude, configuration, spontaneous and insertional activity. Use for intraoperative monitoring of central nervous system tissue during the resection of benign and malignant neoplasia and during corrective surgery for scoliosis may also be needed.
The axon innervating a muscle is primarily responsible for the muscles’ volitional contraction, survival and trophic functions. Prime examples of diseases characterized by abnormal EMG are disc disease with abnormal nerve compression, amyotrophic lateral sclerosis and neuropathies. Axonal and muscle involvement are most sensitively detected by EMGs, and myelin and axonal involvement are best detected by NCV.
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 dosage and wastage of toxin must be documented. It is expected that the accompanying study to the injection be billed as a limited study (95874) unless supportive accompanying documentation is submitted to show why more extensive studies are indicated.
Limitations
Do not report electromyographic studies performed with surface electrodes instead of needle technology with CPT code 95860.
Do not report nerve conduction studies that do not provide real-time conduction amplitude and latency/velocity data with CPT codes 95900, 95903 or 95904.
Do not report nerve conduction studies performed with preconfigured electrode arrays (e.g., NC-Stat®) with CPT codes 93900, 93903 or 93904. See associated article for coding instructions regarding these services.
Sensory nerve function testing performed with various sensory discrimination and pressure-sensitive devices, including but not limited to current perception testing (e.g., Neurometer®), is not covered. Do not report such testing as nerve conduction testing using any CPT code included in this LCD.
Nerve conduction studies and EMG will not be covered if provided in the beneficiary’s home.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, 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.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 21X, 22X, 23X, 71X, 75X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
0920, 0922
CPT/HCPCS Codes
|
Note:
|
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
|
Nerve Conduction Studies
|
95900©
|
Motor nerve conduction test
|
|
95903©
|
Motor nerve conduction test
|
|
95904©
|
Sense nerve conduction test
|
|
95905©
|
Motor/sens nrve conduct test
|
|
95933©
|
Blink reflex test
|
|
95934©
|
H-reflex test
|
|
95936©
|
H-reflex test
|
|
95937©
|
Neuromuscular junction test
|
Electromyography
|
92265©
|
Eye muscle evaluation
|
|
95860©
|
Muscle test, one limb
|
|
95861©
|
Muscle test, two limbs
|
|
95863©
|
Muscle test, 3 limbs
|
|
95864©
|
Muscle test, 4 limbs
|
|
95865©
|
Muscle test, larynx
|
|
95866©
|
Muscle test, hemidiaphragm
|
|
95867©
|
Muscle test, head or neck
|
|
95868©
|
Muscle test, head or neck
|
|
95869©
|
Muscle test, thor paraspinal
|
|
95870©
|
Muscle test, nonparaspinal
|
|
95872©
|
Muscle test, one fiber
|
|
95874©
|
Guide nerv destr, needle emg
|
ICD-9-CM Codes that Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 95865 and 95866:
Covered for:
|
784.49
|
Other voice and resonance disorders
|
Medicare is establishing the following limited coverage for CPT/HCPCS codes 95867 and 95868:
Covered for:
|
005.1
|
Botulism
|
|
037
|
Tetanus
|
|
191.7
|
Malignant neoplasm of brain stem
|
|
192.1–192.2
|
Malignant neoplasm of other and unspecified parts of nervous system (cerebral meninges & spinal cord)
|
|
198.3–198.4
|
Secondary malignant neoplasm of other specified sites (brain and spinal meninges and cord)
|
|
250.60–250.63
|
Diabetes with neurological manifestations
|
|
350.1–350.2
|
Trigeminal nerve disorder
|
|
350.8–350.9
|
Trigeminal nerve disorder, other, unspecified
|
|
351.0–351.1
|
Facial nerve disorder
|
|
351.8–351.9
|
Facial nerve disorder, other, unspecified
|
|
352.0–352.6
|
Disorders of other cranial nerves
|
|
352.9
|
Unspecified disorder of cranial nerves
|
|
357.0
|
Acute infective polyneuritis
|
|
358.00–358.01
|
Myasthenia gravis
|
Medicare is establishing the following limited coverage for CPT/HCPCS codes 95860, 95861, 95863, 95864, 95869, 95900 and 95937 (non-cranial EMG and NCS):
Covered for:
|
005.1
|
Botulism
|
|
037
|
Tetanus
|
|
170.2
|
Malignant neoplasm of vertebral column, excluding sacrum and coccyx
|
|
170.6
|
Malignant neoplasm of pelvic bones, sacrum and coccyx
|
|
191.7
|
Malignant neoplasm of brain stem
|
|
192.2–192.3
|
Malignant neoplasm of other and unspecified parts of nervous system
|
|
198.3–198.5
|
Secondary malignant neoplasm of other specified sites (brain and spinal meninges and cord, bone and bone marrow)
|
|
213.2
|
Benign neoplasm of vertebral column, excluding sacrum and coccyx
|
|
213.6
|
Benign neoplasm of pelvic bones, sacrum and coccyx
|
|
225.3
|
Benign neoplasm of spinal cord
|
|
250.60–250.63
|
Diabetes with neurological manifestations
|
|
265.1
|
Other and unspecified manifestations of thiamine deficiency
|
|
269.1
|
Deficiency of other vitamins
|
|
335.0
|
Werdnig-Hoffmann disease
|
|
335.10–335.11
|
Spinal muscular atrophy
|
|
335.19
|
Other spinal muscular atrophy
|
|
335.20–335.24
|
Amyotrophic lateral sclerosis (ALS)
|
|
335.29
|
Other motor neuron disease
|
|
335.8–335.9
|
Anterior horn cell disease, other, unspecified
|
|
336.0–336.3
|
Other diseases of spinal cord
|
|
336.8–336.9
|
Other myelopathy, unspecified disease of spinal cord
|
|
337.00–337.01
|
Idiopathic peripheral autonomic neuropathy
|
|
337.09
|
Other idiopathic peripheral autonomic neuropathy
|
|
337.1
|
Peripheral autonomic neuropathy in disorders classified elsewhere
|
|
337.20–337.22
|
Reflex sympathetic dystrophy
|
|
337.29
|
Reflex sympathetic dystrophy of other specified site
|
|
337.3
|
Autonomic dysreflexia
|
|
337.9
|
Unspecified disorder of autonomic nervous system
|
|
340
|
Multiple sclerosis
|
|
341.0–341.1
|
Other demyelinating diseases of central nervous system
|
|
341.20-341.22
|
Acute (transverse) myelitis
|
|
341.8–341.9
|
Other demyelinating diseases of central nervous system, unspecified
|
|
342.00–342.02
|
Flaccid hemiplegia
|
|
342.10–342.12
|
Spastic hemiplegia
|
|
342.80–342.82
|
Other specified hemiplegia
|
|
342.90–342.92
|
Hemiplegia, unspecified
|
|
343.0–343.4
|
Infantile cerebral palsy
|
|
343.8–343.9
|
Infantile cerebral palsy, other, unspecified
|
|
344.00–344.04
|
Quadriplegia and quadriparesis
|
|
344.09
|
Other quadriplegia and quadriparesis
|
|
344.1–344.2
|
Paraplegia, diplegia of upper limbs
|
|
344.30–344.32
|
Monoplegia of lower limb
|
|
344.40–344.42
|
Monoplegia of upper limb
|
|
344.5
|
Unspecified monoplegia
|
|
344.60–344.61
|
Cauda equina syndrome
|
|
344.81
|
Locked-in state
|
|
344.89
|
Other specified paralytic syndrome
|
|
344.9
|
Paralysis, unspecified
|
|
353.0–353.6
|
Nerve root and plexus disorders
|
|
353.8–353.9
|
Other nerve root and plexus disorders, unspecified
|
|
354.0–354.5
|
Mononeuritis of upper limb and mononeuritis multiplex
|
|
354.8–354.9
|
Other mononeuritis of upper limb, unspecified
|
|
355.0–355.6
|
Mononeuritis of lower limb and unspecified site
|
|
355.71
|
Causalgia of lower limb
|
|
355.79
|
Other mononeuritis of lower limb
|
|
355.8–355.9
|
Mononeuritis of lower limb, unspecified, unspecified site
|
|
356.0–356.4
|
Hereditary and idiopathic peripheral neuropathy
|
|
356.8–356.9
|
Specified idiopathic peripheral neuropathy, other, unspecified
|
|
357.0–357.7
|
Inflammatory and toxic neuropathy
|
|
357.81–357.82
|
Inflammatory and toxic neuropathy, other
|
|
357.89
|
Other inflammatory and toxic neuropathy
|
|
358.00–358.01
|
Myasthenia gravis
|
|
358.1–358.2
|
Myoneural disorders
|
|
358.8–358.9
|
Specified myoneural disorders, other, unspecified
|
|
359.0–359.1
|
Muscular dystrophies and other myopathies
|
|
359.21–359.24
|
Myotonic Disorders
|
|
359.29
|
Other specified myotonic Disorders
|
|
359.3–359.6
|
Muscular dystrophies and other myopathies
|
|
359.71
|
Inclusion body myositis
|
|
359.79
|
Other inflammatory and immune myopathies, NEC
|
|
359.81
|
Critical illness myopathy
|
|
359.89
|
Other myopathies
|
|
359.9
|
Myopathy, unspecified
|
|
438.32
|
Monoplegia of upper limb affecting non-dominant side
|
|
438.41–438.42
|
Late effect of cerebrovascular disease, monoplegia of lower limb
|
|
710.3–710.5
|
Diffuse diseases of connective tissue
|
|
721.1–721.3
|
Spondylosis and allied disorders
|
|
721.41–721.42
|
Thoracic or lumbar spondylosis with myelopathy
|
|
721.91
|
Spondylosis of unspecified site with myelopathy
|
|
722.0
|
Displacement of cervical intervertebral disc without myelopathy
|
|
722.10–722.11
|
Displacement of thoracic or lumbar intervertebral disc without myelopathy
|
|
722.2
|
Displacement of intervertebral disc, site unspecified, without myelopathy
|
|
722.70–722.73
|
Intervertebral disc disorder with myelopathy
|
|
722.80–722.83
|
Postlaminectomy syndrome
|
|
723.0–723.5
|
Other disorders of cervical region
|
|
724.00–724.03
|
Spinal stenosis, other than cervical
|
|
724.09
|
Other spinal stenosis
|
|
724.1
|
Pain in thoracic spine
|
|
724.3–724.4
|
Sciatica, thoracic or lumbosacral neuritis or radiculitis, unspecified
|
|
728.0
|
Infective myositis
|
|
728.88
|
Rhabdomyolysis
|
|
729.5
|
Pain in limb
|
|
736.05–736.06
|
Acquired deformities of forearm, excluding fingers
|
|
737.30
|
Scoliosis, idiopathic
|
|
781.0
|
Abnormal involuntary movements
|
|
781.2–781.3
|
Symptoms involving nervous and musculoskeletal systems
|
|
781.6
|
Meningismus
|
|
782.0
|
Disturbance of skin sensation (paresthesia)
|
|
784.49
|
Other voice and resonance disorders
|
|
951.4
|
Injury to facial nerve
|
|
951.6–951.7
|
Injury to accessory nerve, hypoglossal nerve
|
|
952.00–952.09
|
Spinal cord injury without evidence of spinal bone injury, cervical
|
|
952.10–952.19
|
Spinal cord injury without evidence of spinal bone injury, dorsal [thoracic]
|
|
952.2–952.4
|
Spinal cord injury without evidence of spinal bone injury, lumbar, sacral, cauda equina
|
|
952.8–952.9
|
Spinal cord injury without evidence of spinal bone injury, multiple sites of spinal cord, unspecified site of spinal cord
|
|
953.0–953.5
|
Injury to nerve roots and spinal plexus
|
|
953.8–953.9
|
Injury to multiple sites, unspecified site
|
|
954.0–954.1
|
Injury to other nerve(s) of trunk, excluding shoulder and pelvic girdles
|
|
954.8–954.9
|
Injury to other specified nerve(s) of trunk, unspecified nerve of trunk
|
|
955.0–955.9
|
Injury to peripheral nerve(s) of shoulder girdle and upper limb
|
|
956.0–956.5
|
Injury to peripheral nerve(s) of pelvic girdle and lower limb
|
|
956.8–956.9
|
Injury to multiple nerves of pelvic girdle and lower limb, unspecified
|
|
957.0–957.1
|
Injury to superficial nerves
|
|
957.8–957.9
|
Injury to multiple nerves in several parts, unspecified site
|
Medicare is establishing the following limited coverage for CPT/HCPCS codes 95870, 95872, 95904, 95905 and 95933 (non-cranial EMG and NCS):
Covered for:
|
005.1
|
Botulism
|
|
037
|
Tetanus
|
|
192.2–192.3
|
Malignant neoplasm of other and unspecified parts of nervous system
|
|
250.60–250.63
|
Diabetes with neurological manifestations
|
|
265.1
|
Other and unspecified manifestations of thiamine deficiency
|
|
269.1
|
Deficiency of other vitamins
|
|
335.0
|
Werdnig-Hoffmann disease
|
|
335.10–335.11
|
Spinal muscular atrophy
|
|
335.19
|
Other spinal muscular atrophy
|
|
335.20–335.24
|
Amyotrophic lateral sclerosis (ALS)
|
|
335.29
|
Other motor neuron disease
|
|
335.8–335.9
|
Anterior horn cell disease , other, unspecified
|
|
336.0–336.3
|
Other diseases of spinal cord
|
|
336.8–336.9
|
Other myelopathy, unspecified disease of spinal cord
|
|
Idiopathic peripheral autonomic neuropathy
|
|
|
337.09
|
Other idiopathic peripheral autonomic neuropathy
|
|
337.1
|
Peripheral autonomic neuropathy in disorders classified elsewhere
|
|
337.20–337.22
|
Reflex sympathetic dystrophy
|
|
337.29
|
Reflex sympathetic dystrophy of other specified site
|
|
337.3
|
Autonomic dysreflexia
|
|
337.9
|
Unspecified disorder of autonomic nervous system
|
|
340
|
Multiple sclerosis
|
|
341.0–341.1
|
Other demyelinating diseases of central nervous system
|
|
341.20-341.22
|
Acute (transverse) myelitis
|
|
341.8–341.9
|
Other demyelinating diseases of central nervous system, unspecified
|
|
342.00–342.02
|
Flaccid hemiplegia
|
|
342.10–342.12
|
Spastic hemiplegia
|
|
342.80–342.82
|
Other specified hemiplegia
|
|
342.90–342.92
|
Hemiplegia, unspecified
|
|
343.0–343.4
|
Infantile cerebral palsy
|
|
343.8–343.9
|
Infantile cerebral palsy, other, unspecified
|
|
344.00–344.04
|
Quadriplegia and quadriparesis
|
|
344.09
|
Other quadriplegia and quadriparesis
|
|
344.1–344.2
|
Paraplegia, diplegia of upper limbs
|
|
344.30–344.32
|
Monoplegia of lower limb
|
|
344.40–344.42
|
Monoplegia of upper limb
|
|
344.5
|
Unspecified monoplegia
|
|
344.60–344.61
|
Cauda equina syndrome
|
|
344.81
|
Locked-in state
|
|
344.89
|
Other specified paralytic syndrome
|
|
344.9
|
Paralysis, unspecified
|
|
353.0–353.6
|
Nerve root and plexus disorders
|
|
353.8–353.9
|
Other nerve root and plexus disorders, unspecified
|
|
354.0–354.5
|
Mononeuritis of upper limb and mononeuritis multiplex
|
|
354.8–354.9
|
Other mononeuritis of upper limb, unspecified
|
|
355.0–355.6
|
Mononeuritis of lower limb and unspecified site
|
|
355.71
|
Causalgia of lower limb
|
|
355.79
|
Other mononeuritis of lower limb
|
|
355.8–355.9
|
Mononeuritis of lower limb, unspecified, unspecified site
|
|
356.0–356.4
|
Hereditary and idiopathic peripheral neuropathy
|
|
356.8–356.9
|
Specified idiopathic peripheral neuropathy, other, unspecified
|
|
357.0–357.7
|
Inflammatory and toxic neuropathy
|
|
357.81–357.82
|
Inflammatory and toxic neuropathy, other
|
|
357.89
|
Other inflammatory and toxic neuropathy
|
|
358.00–358.01
|
Myasthenia gravis
|
|
358.1–358.2
|
Myoneural disorders
|
|
358.8–358.9
|
Specified myoneural disorders, other, unspecified
|
|
359.0–359.1
|
Muscular dystrophies and other myopathies
|
|
359.21–359.24
|
Myotonic Disorders
|
|
359.29
|
Other specified myotonic Disorders
|
|
359.3–359.6
|
Muscular dystrophies and other myopathies
|
|
359.71
|
Inclusion body myositis
|
|
359.79
|
Other inflammatory and immune myopathies, NEC
|
|
359.81
|
Critical illness myopathy
|
|
359.89
|
Other myopathies
|
|
359.9
|
Myopathy, unspecified
|
|
438.32
|
Monoplegia of upper limb affecting non-dominant side
|
|
438.41–438.42
|
Late effect of cerebrovascular disease, monoplegia of lower limb
|
|
710.3–710.5
|
Diffuse diseases of connective tissue
|
|
721.1–721.3
|
Spondylosis and allied disorders
|
|
721.41–721.42
|
Thoracic or lumbar spondylosis with myelopathy
|
|
721.91
|
Spondylosis of unspecified site with myelopathy
|
|
722.0
|
Displacement of cervical intervertebral disc without myelopathy
|
|
722.10–722.11
|
Displacement of thoracic or lumbar intervertebral disc without myelopathy
|
|
722.2
|
Displacement of intervertebral disc, site unspecified, without myelopathy
|
|
722.70–722.73
|
Intervertebral disc disorder with myelopathy
|
|
722.80–722.83
|
Postlaminectomy syndrome
|
|
723.0–723.5
|
Other disorders of cervical region
|
|
724.00–724.03
|
Spinal stenosis, other than cervical
|
|
724.09
|
Other spinal stenosis
|
|
724.1
|
Pain in thoracic spine
|
|
724.3–724.4
|
Sciatica, thoracic or lumbosacral neuritis or radiculitis, unspecified
|
|
728.0
|
Infective myositis
|
|
728.88
|
Rhabdomyolysis
|
|
729.5
|
Pain in limb
|
|
736.05–736.06
|
Acquired deformities of forearm, excluding fingers
|
|
781.0
|
Abnormal involuntary movements
|
|
781.2–781.3
|
Symptoms involving nervous and musculoskeletal systems
|
|
781.6
|
Meningismus
|
|
782.0
|
Disturbance of skin sensation (paresthesia)
|
|
784.49
|
Other voice and resonance disorders
|
|
951.4
|
Injury to facial nerve
|
|
951.6–951.7
|
Injury to accessory nerve, hypoglossal nerve
|
|
952.00–952.09
|
Spinal cord injury without evidence of spinal bone injury, cervical
|
|
952.10–952.19
|
Spinal cord injury without evidence of spinal bone injury, dorsal [thoracic]
|
|
952.2–952.4
|
Spinal cord injury without evidence of spinal bone injury, lumbar, sacral, cauda equina
|
|
952.8–952.9
|
Spinal cord injury without evidence of spinal bone injury, multiple sites of spinal cord, unspecified site of spinal cord
|
|
953.0–953.5
|
Injury to nerve roots and spinal plexus
|
|
953.8–953.9
|
Injury to multiple sites, unspecified site
|
|
954.0–954.1
|
Injury to other nerve(s) of trunk, excluding shoulder and pelvic girdles
|
|
954.8–954.9
|
Injury to other specified nerve(s) of trunk, unspecified nerve of trunk
|
|
955.0–955.9
|
Injury to peripheral nerve(s) of shoulder girdle and upper limb
|
|
956.0–956.5
|
Injury to peripheral nerve(s) of pelvic girdle and lower limb
|
|
956.8–956.9
|
Injury to multiple nerves of pelvic girdle and lower limb, unspecified
|
|
957.0–957.1
|
Injury to superficial nerves
|
|
957.8–957.9
|
Injury to multiple nerves in several parts, unspecified site
|
Medicare is establishing the following limited coverage for CPT/HCPCS codes 95903, 95934 and 95936 (F-wave and H-reflex):
Covered for:
|
192.2–192.3
|
Malignant neoplasm of other and unspecified parts of nervous system
|
|
353.0–353.1
|
Nerve root and plexus disorders
|
|
353.4
|
Lumbosacral root lesions
|
|
354.1–354.5
|
Mononeuritis of upper limb and mononeuritis multiplex
|
|
354.8–354.9
|
Other mononeuritis of upper limb, unspecified
|
|
355.0–355.4
|
Mononeuritis of lower limb and unspecified site
|
|
355.6
|
Lesion of plantar nerve
|
|
355.71
|
Causalgia of lower limb
|
|
355.79
|
Other mononeuritis of lower limb
|
|
355.8–355.9
|
Mononeuritis of lower limb, unspecified, unspecified site
|
|
356.0–356.4
|
Hereditary and idiopathic peripheral neuropathy
|
|
356.8–356.9
|
Specified idiopathic peripheral neuropathy, other, unspecified
|
|
357.0–357.7
|
Inflammatory and toxic neuropathy
|
|
357.81–357.82
|
Inflammatory and toxic neuropathy, other
|
|
357.89
|
Other inflammatory and toxic neuropathy
|
|
357.9
|
Unspecified polyneuropathy
|
|
721.1
|
Cervical spondylosis with myelopathy
|
|
721.41–721.42
|
Thoracic or lumbar spondylosis with myelopathy
|
|
723.4
|
Brachial neuritis or radiculitis NOS
|
|
724.3–724.4
|
Sciatica, thoracic or lumbosacral neuritis or radiculitis, unspecified
|
|
781.2–781.3
|
Symptoms involving nervous and musculoskeletal systems
|
|
953.2–953.3
|
Injury to nerve roots and spinal plexus
|
|
953.5
|
Injury to lumbosacral plexus
|
|
956.0–956.5
|
Injury to peripheral nerve(s) of pelvic girdle and lower limb
|
|
956.8–956.9
|
Injury to multiple nerves of pelvic girdle and lower limb, unspecified
|
Medicare is establishing the following limited coverage for CPT/HCPCS code 95874 when EMG is used for directed treatment of botulinum toxin injections (J0585 and J0587):
Covered for:
|
333.6
|
Genetic torsion dystonia
|
|
333.71
|
Athetoid cerebral palsy
|
|
333.79
|
Other acquired torsion dytonia
|
|
333.81–333.84
|
Fragments of torsion dystonia
|
|
333.89
|
Other, fragments of torsion dystonia
|
|
334.1
|
Hereditary spastic paraplegia
|
|
340
|
Multiple sclerosis
|
|
341.0–341.1
|
Other demyelinating diseases of central nervous system
|
|
341.20–341.22
|
Acute (transverse) myelitis
|
|
341.8–341.9
|
Other demyelinating diseases of central nervous system
|
|
342.11–342.12
|
Spastic hemiplegia
|
|
343.0–343.4
|
Infantile cerebral palsy
|
|
343.8–343.9
|
Infantile cerebral palsy
|
|
344.00–344.04
|
Quadriplegia and quadriparesis
|
|
351.8
|
Other facial nerve disorder; facial spasm
|
|
378.00–378.08
|
Esotropia
|
|
378.10–378.18
|
Exotropia
|
|
378.20–378.24
|
Intermittent heterotropia
|
|
378.30–378.35
|
Other and unspecified heterotropia
|
|
378.40–378.45
|
Heterophoria
|
|
378.50–378.56
|
Paralytic strabismus
|
|
378.60–378.63
|
Mechanical strabismus
|
|
378.71–378.73
|
Other specified strabismus
|
|
378.81–378.87
|
Other disorders of binocular eye movements
|
|
378.9
|
Unspecified disorder of eye movement
|
|
438.31–438.32
|
Monoplegia of upper limb
|
|
438.41–438.42
|
Monoplegia of lower limb
|
|
478.75
|
Laryngeal spasm
|
|
478.79
|
Other disease of the larynx (dysphonia spastica)
|
|
530.0
|
Achalasia and cardiospasm
|
|
723.5
|
Torticollis, unspecified
|
|
728.85
|
Spasm of muscle
|
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses that Support Medical Necessity
N/A
ICD-9-CM Codes that DO NOT Support Medical Necessity
N/A
Diagnoses that DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes that Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request. Refer to the table under “Indications and Limitations of Coverage and/or Medical Necessity” for specific documentation requirements.
- It is expected that the NCV and EMG reports will contain data from the study as well as the interpretation and diagnosis.
- In the event of a review for medical necessity, the patient’s medical record must support the need for the studies performed. The number of limbs or areas tested should be the minimum needed to evaluate the patient’s condition. Repeat testing should be infrequent; limitation of testing services will be determined on the basis of individual medical necessity. However, documentation of services exceeding the TrailBlazer guidelines or the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) guidelines must be verifiable and clearly documented in the patient’s medical record, with the documentation justifying all testing that exceeds recommended parameters. An excessive number of services may result in a delay in processing, a denial of the claim or a request for a refund.
- Documentation addressing the need to evaluate the patient for peripheral neuropathy must be maintained by the practitioner and made available to Medicare upon request.
- Documentation addressing the indications and circumstances requiring individual nerve conduction studies (without accompanying EMG) must be maintained by the practitioner, and made available upon request.
- Credentials of providers billing for needle electromyography must be available on request.
- The record must reflect the need for EMG to localize the optimal injection site for the botulinum toxin; the dose injected and any reported wastage must be recorded in the record.
- When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.
Medicare will reimburse for the following numbers of tests per year per patient:
- 95900 – eight/year
- 95903 – eight/year
- 95904 – ten/year
- 95905 – one per limb/year or no more than four per year
- 95934 – two/year
- 95936 – two/year
Payment for additional tests will require medical record review during a requested redetermination.
It is expected that providers will use 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 codes 95860, 95861, 95863 or 95864 are also billed.
Medicare would not expect to see multiple uses of EMG in the same patient at the same location for the purpose of optimizing botulinum toxin injections.
Medicare does not expect to see 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.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Integration
TrailBlazer adopted the TrailBlazer LCD, “Electrodiagnostic Studies (NCS/EMG)” for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of information sources is found with original contractor LCDs.
