Medical Policy Department Clinical Affairs Division

Nerve Conduction Velocity (NCV) & Electromyography (EMG) Studies

[Preauthorization Required]

Medical Policy: Original Effective Date: Reviewed: Reviewed:

MP-ME-09-09 November 5, 2010 November 5, 2010 November 2, 2011

This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and Medical Card System, Inc., providers contract, unless specific contract limitations, exclusions or exceptions apply. Please refer to the members benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions.

DESCRIPTION
Nerve Conduction Velocity Studies (NCV) measures the speed of conduction of impulses through a nerve. The impulses being measured are artificially supplied by a stimulating electrode placed on the skin over the nerve. Electrical activity in the nerve being stimulated is measured by recording electrodes placed on the skin at various distances from the stimulating electrode. The distance between the stimulating and recording electrodes and the time taken for an electrical impulse to travel between the electrodes are used to calculate the nerve conduction velocity. Nerve conduction tests have two parts testing motor and sensory nerve testing. Nerve conduction velocity studies are performed to evaluate and document a variety of sensory and motor neuropathological conditions in patients with a suspected diagnosis of nerve dysfunction. Nerve dysfunction can be manifested in decreased signal amplitude, slowed conduction velocity or increased latency. Proximal and distal nerve segments may be tested separately to help identify and localize the cause of the patients condition. Additional tests are sometimes used to evaluate the results of treatment. Although the stimulation of nerves is similar with all NCV studies, the characteristics of motor, sensory, and mixed NCS are different.

Motor NCV studies 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. Sensory NCV studies 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, configuration, and sensory conduction velocity. Mixed NCV studies are performed by applying electrical stimulation near a nerve containing both
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Medical Policy Department Clinical Affairs Division

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 both sensory and motor conduction velocity. Another type of NCV studies is referred to as late response (H-reflex and F-wave testing) and is usually performed on nerves more proximal to the spine. These segments include the first several centimeters of a compound nerve emerging from the spinal cord or brainstem. They are helpful in diagnosing conditions of radiculopathies, plexopathies, polyneuropathies, and proximal mononeuropathies. Late response studies are additional studies complementary to NCV and are performed during the same patient evaluation. Nerve Conduction Velocity Studies (NCV) and Needle electromyography (EMG) are typically performed together, by trained and qualified practitioners. Both NCV and EMG are used for clinical diagnosis of peripheral nervous system disorders. Electromyography (EMG) is the study and recording of Intrinsic Electrical Properties of Skeletal muscles. This testing is invasive because it requires needle insertion and adjustment at multiple sites, and at anatomically critical areas.

COVERAGE
Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits, and coverage.

INDICATIONS
I. Medical Card System, Inc., (MCS) considers Nerve Conduction Velocity Studies (NCV) medically necessary under the following conditions: Focal neuropathies or compressive lesions such a 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 or immune Repetitive nerve stimulation in diagnosis of Neuromuscular Junction disorders such as Myasthenia Gravis, Myasthemic Syndrome

II.

MCS considers Electromyography (EMG) medically necessary under the following conditions: Nerve Compression Syndromes, including carpal tunnel syndrome and other focal compressions Radiculophaty-Cervical, Lumbosacral Mononeuropathy/Polyneuropathy-Metabolic, degenerative, hereditary
2

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Medical Policy Department Clinical Affairs Division

Plexopathy-idiopathic, trauma, infiltration Myopathy-including Poly and dermatomyositis, Myotonic and Congenital Myopathies Neuromuscular Junction disorders-Myasthenia Gravis (Single fiber EMG (95872) is of special value here.)

III. MCS will consider Repeated Nerve Conduction Velocity Studies under the following circumstances:
Repeating nerve conduction velocity studies should be based on clinical justification and there should be evidence-based documentation for any repeated study. Repeated nerve conduction velocity studies could be seen after an initial diagnosis has been made for the following conditions: a. For a patient with worsening signs and symptoms; b. For new trauma or injury to the affected area; and/or c. For a patient who is being managed medically for a condition and is not showing signs of improvement using current prescribed modalities. Repeated nerve conduction velocity studies should only be performed for conditions that require medical management and meet the coverage criteria listed in this policy. Not more than two electrodiagnostic evaluations per 12-month period are generally accepted for carpal tunnel syndrome, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction disease. Not more than three electrodiagnostic evaluations in a 12-month period are generally accepted for motor neuropathy and plexopathy.

CONTRAINDICATIONS/LIMITATIONS
Consistent excessive use of units of testing, repeated testing on the same patient, or testing every patient referred for pain, weakness or paresthesia. The NCV-EMG performing provider, in addition to the referring provider, is responsible for determination of the appropriateness of the studies. Refer to Appendix A-Frequency of Testing; which includes the maximum of Studies permitted with medical necessity. Electrodiagnostic studies are covered when performed by providers of Neurology and Physiatrists services, or other trained providers who have a detailed knowledge of neuromuscular diseases and awareness of the influence of age, temperature, and body height on the results. Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty, or; If these skills have been acquired as continuing medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the
3

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Medical Policy Department Clinical Affairs Division

United States or Puerto Rico, and designated by the American Medical Association (AMA). Codes 95860, 95861, 95863, 95864, 95867, 95868, 95869, and 95870 require level 6a supervision, which means the service must be performed personally by the physician or a Physical therapist who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist AND is permitted to provide the service under state law. Codes 95900, 95903, 95904, 95934, 95936 and 95937 require level 7a supervision which means the services must be personally performed by a physician, or by a physical therapist with (ABPTS) certification, or by a physical therapist lacking certification but under the direct supervision of a Physician, or by a technician with a certification under the general supervision of a physician. Segmental testing of a single nerve represents a single study. For example, a test of the ulnar nerve at wrist, forearm, below elbow, above elbow, axilla, and supraclavicular regions represents one test. Similarly, the use of different methods of measuring the conduction in the same nerve, such as orthodromic and antidromic testing, constitutes one study. The number of tests (units of each CPT code) performed should be the minimum needed to establish an accurate diagnosis. On a particular day of testing, the number of tests performed/nerves tested should not exceed the number of tests/nerves indicated in the table Appendix A-Frequency of Testing, and exceptions may result in medical review. Categorically, there are general standards accepted for repeat electrodiagnostic testing in certain categories of diseases. Not more than two electrodiagnostic evaluations per 12-month period are generally accepted for carpal tunnel syndrome, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction disease. Not more than three electrodiagnostic evaluations in a 12-month period are generally accepted for motor neuropathy and plexopathy. Therefore, repeat electrodiagnostic testing should not be needed in a 12-month period in the majority of all cases. Documentation should be available to verify the need for repeat testing on any patient.

Note: Sensory Nerve Conduction Threshold Test (sNCT) is not considered medically necessary by MCS. All uses of sNCT to diagnose sensory neuropathies or radiculopathies are not considered medically necessary.

MCS considers the following to be experimental and investigational:

Examination/NCV studies using the NC-stat monitor, the Brevio NCS monitor, the Neural-Scan, and other automated devices are considered experimental and investigational.

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Medical Policy Department Clinical Affairs Division

NCV studies are considered experimental and investigational for screening for polyneuropathy of diabetes or end-stage renal disease.

CODING INFORMATION CPT Codes for Nerve Conduction Velocity Studies (NCS)
CPT Codes 95900 DESCRIPTION Nerve Conduction, amplitude and latency/velocity study. Each nerve; motor, without F-wade study Nerve Conduction, amplitude and latency/velocity study, each nerve motor, with Fwade study Nerve Conduction, amplitude and latency/velocity study, each nerve; sensory 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 H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle H-reflex, amplitude and gastrocnemius/soleus muscle latency study; record muscle other than

95903

95904 95905

95934 95936

95937

Neuromuscular junction testing (Repetitive stimulation, paired stimuli), each nerve, any one method

*Current Procedural Terminology (CPT) 2011 American Medical Association: Chicago, IL.

CPT Codes for Electromyography (EMG)

CPT Codes 95860 95861 95863 95864 95867 DESCRIPTION Needle electromyography; one extremity with or without related paraspinal areas Needle electromyography; two extremities with or without related paraspinal areas Needle electromyography; three extremities with or without related paraspinal areas Needle electromyography; Four extremities with or without related paraspinal areas Needle electromyography; Cranial Nerve supplied Muscle(s), Unilateral

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Medical Policy Department Clinical Affairs Division

95868 95869 95870 Needle electromyography, Cranial Nerve Supplied Muscles, Bilateral Needle Electromyography; Thoracic Paraspinal Muscles (Excluding T1 or T2) Needle Electromyography; Limited study of Muscle in One Extremity or Non-Limb (Axial) Muscles (Unilateral or Bilateral), other than thoracic Paraspinal, cranial nerve supplied muscles, or sphinters Needle electromyography using single fiber electrode, with quantitative measurement of Jitter, Blocking and/or fiber density, any/all sites of each muscle studied

95872

*Current Procedural Terminology (CPT) 2011 American Medical Association: Chicago, IL.

ICD-9 CM Diagnosis Codes

ICD-9 CM CODES 192.2 192.3 198.3 198.4 250.60 250.63 DESCRIPTION

MALIGNANT NEOPLASM OF SPINAL CORD MALIGNANT NEOPLASM OF SPINAL MENINGES SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED OTHER AND UNSPECIFIED MANIFESTATIONS OF THIAMINE DEFICIENCY DEFICIENCY OF OTHER VITAMINS WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED

265.1 269.1 335.0 335.9 336.0 336.9 337.00 337.01

SYRINGOMYELIA AND SYRINGOBULBIA - UNSPECIFIED DISEASE OF SPINAL CORD

IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY, UNSPECIFIED CAROTID SINUS SYNDROME

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Medical Policy Department Clinical Affairs Division

337.09 337.20 337.29 337.3 340 341.0 341.9 344.00 344.9 350.1 350.9 351.0 351.8 352.3 352.4 352.5 352.6 353.0 353.1 353.2 353.3 353.4 353.5 354.0 354.9 OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY REFLEX SYMPATHETIC DYSTROPHY UNSPECIFIED - REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE AUTONOMIC DYSREFLEXIA MULTIPLE SCLEROSIS NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED QUADRIPLEGIA UNSPECIFIED - PARALYSIS UNSPECIFIED

TRIGEMINAL NEURALGIA - TRIGEMINAL NERVE DISORDER UNSPECIFIED

BELL'S PALSY OTHER FACIAL NERVE DISORDERS DISORDERS OF PNEUMOGASTRIC (10TH) NERVE DISORDERS OF ACCESSORY (11TH) NERVE DISORDERS OF HYPOGLOSSAL (12TH) NERVE MULTIPLE CRANIAL NERVE PALSIES BRACHIAL PLEXUS LESIONS LUMBOSACRAL PLEXUS LESIONS CERVICAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED THORACIC ROOT LESIONS NOT ELSEWHERE CLASSIFIED LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED NEURALGIC AMYOTROPHY CARPAL TUNNEL SYNDROME - MONONEURITIS OF UPPER LIMB UNSPECIFIED

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Medical Policy Department Clinical Affairs Division

355.0 355.9 356.0 356.9 357.0 357.9 358.00 358.01 358.1* 359.0 359.9 368.2 378.73 710.4 721.0 721.91 722.4 722.51 722.52 722.80 722.83 723.1 723.4 724.2 724.3 724.4 LESION OF SCIATIC NERVE - MONONEURITIS OF UNSPECIFIED SITE

HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY ACUTE INFECTIVE POLYNEURITIS - UNSPECIFIED INFLAMMATORY AND TOXIC NEUROPATHIES MYASTHENIA GRAVIS WITHOUT (ACUTE) EXACERBATION - MYASTHENIA GRAVIS WITH (ACUTE) EXACERBATION MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE CONGENITAL HEREDITARY MUSCULAR DYSTROPHY - MYOPATHY UNSPECIFIED

DIPLOPIA STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS POLYMYOSITIS CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY - SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY DEGENERATION OF CERVICAL INTERVERTEBRAL DISC DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRAL DISC DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC POSTLAMINECTOMY SYNDROME OF UNSPECIFIED REGION - POSTLAMINECTOMY SYNDROME OF LUMBAR REGION CERVICALGIA BRACHIAL NEURITIS OR RADICULITIS NOS LUMBAGO SCIATICA THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED

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Medical Policy Department Clinical Affairs Division

728.2 728.85 728.87 729.5 729.71 729.72 736.05 736.79 780.79 781.2 781.3 781.4 782.0 787.20 787.29 952.00 952.09 952.10 952.19 952.2 952.3 952.4 952.8 MUSCULAR WASTING AND DISUSE ATROPHY NOT ELSEWHERE CLASSIFIED SPASM OF MUSCLE MUSCLE WEAKNESS (GENERALIZED) PAIN IN LIMB NONTRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY NONTRAUMATIC COMPARTMENT SYNDROME OF LOWER EXTREMITY WRIST DROP (ACQUIRED) OTHER ACQUIRED DEFORMITIES OF ANKLE AND FOOT OTHER MALAISE AND FATIGUE ABNORMALITY OF GAIT LACK OF COORDINATION TRANSIENT PARALYSIS OF LIMB DISTURBANCE OF SKIN SENSATION DYSPHAGIA, UNSPECIFIED - OTHER DYSPHAGIA

C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED - C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED - T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY LUMBAR SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY SACRAL SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY CAUDA EQUINA SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY MULTIPLE SITES OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

*2011 ICD-9-CMFor Physicians, VOLUMES I & II, Professional Edition (American Medical Association)

* According to the 2007 ICD-9-CM book, diagnosis code 358.1 is a manifestation code and not allowed to be reported as a primary diagnosis code.
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Medical Policy Department Clinical Affairs Division

HCPCS CODES NOT COVERED

HCPCS CODES G0255 DESCRIPTION CURRENT PERCEPTION THRESHOLD/SENSORY NERVE CONDDUCTION TEST,(SNCT) PER LIMB, ANY NERVE NON-INVASIVE ELECTRODIAGNOSTIC TESTING WITH AUTOMATIC COMPUTERIZED HAND-HELD DEVICE TO STIMULATE AND MEASURE NEUROMUSCULAR SIGNALS IN DIAGNOSING AND EVALUATING SYSTEMIC AND ENTRAPMENT NEUROPHATHIES

S3905

*2011 HCPCS LEVEL II Professional Edition (American Medical Association).

REFERENCES
1. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), Proper Performance and Interpretation of Electrodiagnostic Studies. September 2005. www.aanem.org/practiceissues/positionstatement/positionstatments.cfm 2. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), Recommended Policy for Electrodiagnostic Medicine. Endorsed by the American Academy of Neurology. The American Academy of Physical Medicine and Rehabilitation and the American Association of Neuromuscular and Electrodiagnostic Medicine. www.aanem.org/practiceissues/recPolicy/recommended_policy_1.cfm 3. American Association of Neuromuscular and Electrodiagnostic Medicine (AAEM), Who is qualified to practice electrodiagnostic medicine. Position statement. Approved May 1999. www.aanem.org/practiceissues/positionstatements/who%27s_Qualified.cfm 4. First Coast Service Options, Inc. LCD for Electromyography and Nerve Conduction Studies (L29325). Determination Effective Date: 1/1/2010. Last review 06/14/2011. Accessed 11/03/2011. No changes for medical Indications. Available at http://www.cms.gov/medicarecoverage-database/license/cptlicense.aspx?from=http*3a%24%2f%2fwww.cms.gov%2fmedicare-coveragedatabase%2findexes%2flcdlist.aspx%3fCntrctr%3d198%26ContrVer%3d1%26CntrctrSelected%3d198*1%26name%3dFirst% 2bCoast%2bService%2bOptions%2c%2bInc.%2b(09202%2c%2bMAC%2b%2bPart%2bB)%26s%3d46%26bc%3dAggAAAAAAAAA%26&npage=/medicare-coveragedatabase/details/lcddetails.aspx&LCDId=29325&ContrId=198&ver=8&ContrVer=1&CntrctrSelected=198*1&Cntrctr= 198&name=First+Coast+Service+Options%2c+Inc.+(09202%2c+MAC++Part+B)&s=46&bc=AggAAAIAAAAA&
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Medical Policy Department Clinical Affairs Division

5. NCS System. NeuroMetrix. Nerve Conduction on Studies. 2008. 6. www.ECRI.org. Point of Care Nerve Conduction Tests. Published: 05/02/2007.

POLICY HISTORY DATE

November 5, 2009 November 5, 2010 November 2, 2011

ACTION
Origination of Policy Yearly Review Yearly Review

COMMENT

Added code 95905

This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the members plan in effect as of the date services are rendered. Medical Card System, Inc., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion Medical Card System, Inc., (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plans ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide.

APPENDIX A-Frequency of Testing

The following table lists the American Association of Neuromuscular & Electrodiagnostic Medicine's (formerly known as American Association of Electrodiagnostic Medicine) recommendations concerning a reasonable maximum number of NCV studies, needle EMG and other EMG studies per diagnostic category needed for a physician to render a diagnosis. Each number in the Maximum Number of Studies Table represents 1 study or Unit.

Table : Maximum Number of Studies

Needle Electromyography, CPT 95860-95864 and Nerve Conduction Studies CPT 95900, Other Electromyographic Studies CPT 95934, 95936,

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Medical Policy Department Clinical Affairs Division

95867-95870 Indications Number of Services (Tests) 95903, 95904 Motor NCS with And/or without F wave 3 4 3 3 4 Sensory NCS HReflex 95937 Neuromuscular Junction Testing (Repetitive Stimulation)

Carpal Tunnel (Unilateral) Carpal Tunnel (Bilateral) Radiculopathy Mononeurophathy Polyneuropathy/Mononeuropathy Multiplex Myopathy Motor Neuronopathy (e.g., ALS) Plexopathy Neuromuscular Junction Tarsal Tunnel Syndrome (Unilateral) Tarsal Tunnel Syndrome (Bilateral) Weakness, Fatigue, Cramps, or Twitching (focal) Weakness, Fatigue, Cramps, or Twitching (General) Pain, Numbness, or Tingling (Unilateral) Pain, Numbness, or Tingling (Bilateral)

1 2 2 1 3

4 6 2 3 4

2 2 2

2 4 2 2 1 2 2

2 4 4 2 4 5 3

2 2 6 2 4 6 4

2 2 3

1 2

3 4

4 6

2 2

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