Electrodiagnostic medicine (EDX) evaluation, which includes electromyography (EMG) and nerve conduction studies (NCS), is an important component of the clinical evaluation of patients with disorders of the peripheral and/or central nervous system. EMG is performed to evaluate the health of muscles and the nerve cells (motor neurons) that control them. Nerve conduction tests identify nerve damage by measuring how fast an electrical impulse moves through a nerve. When it comes to reimbursement for these services, the support of a medical coding service provider that is knowledgeable about billing for EDX services is crucial. Due to the potential for overuse of some EDX procedures by individual providers, insurance companies scrutinize claims thoroughly, knowing how to code and bill EMG and NCS is necessary avoid audits.
Indications for the Performance of EDX Testing
The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) and other medical organizations, including the AMA and the American Academy of Neurology, have published guidelines about proper qualifications for qualified health care professionals performing electrodiagnostic evaluations and payers including Medicare go by these guidelines. In order to provide the proper testing and assessment of the patient’s condition, and appropriate safety measures, payers expect the 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).
EDX testing is performed as part of an EDX evaluation for diagnosis or as follow-up of an existing condition. In addition to neurologists and physical medicine and rehabilitation physicians trained in neuromuscular disease diagnosis, internists, primary care physicians, neurological and orthopedic surgeons, and other healthcare providers may refer patients for EDX studies. It is expected that the EDX physician can arrive at the correct diagnosis only after the completion of the EDX evaluation.
Need assistance with coding for electromyography (EMG) and nerve conduction studies?
AANEM lists the indications for EDX studies as follows:
- Identify normal and abnormal nerve, muscle, motor or sensory neuron, and NMJ functioning.
- Localize region(s) of abnormal function
- Define the type of abnormal function
- Determine the distribution of abnormalities
- Determine the severity of abnormalities
- Estimate the date of a specific nerve injury
- Estimate the duration of the disease
- Determine the progression of abnormalities or of recovery from abnormal function
- Aid in diagnosis and prognosis of disease
- Aid in selecting treatment options
- Aid in following response to treatment by providing objective evidence of change in NM function
- Localize correct locations for injection of intramuscular agents (e.g., botulinum toxin)
CPT Codes for EDX Studies
- Electromyography
- 51785 Needle electromyography studies (EMG) of anal or urethral sphincter, any technique
- 92265 Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and report
- 95860 Needle electromyography, one extremity with or without related paraspinal areas
- 95861 Needle electromyography, two extremities with or without related paraspinal areas
- 95863 Needle electromyography, three extremities with or without related paraspinal areas
- 95864 Needle electromyography, four extremities with or without related paraspinal areas
- 95865 Needle Electromyography; larynx
- 95866 Needle electromyography: hemidiaphragm
- 95867 Needle electromyography, cranial nerve supplied muscles, unilateral
- 95868 Needle electromyography, cranial nerve supplied muscles, bilateral
- 95869 Needle electromyography; thoracic paraspinal muscles
- 95870 Limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles or sphincters
- 95872 Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied
- 95874 Needle electromyography for guidance in conjunction with chemodenervation (list separately in addition to code for primary procedure)
- 95885 Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (list separately in addition to code for primary procedure)
- 95886 Complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (list separately in addition to code for primary procedure)
- 95887 Needle electromyography, non-extremity (cranial nerve supplied or axial) muscles(s) done with nerve conduction, amplitude and latency/velocity studies (list separately in addition to code for primary procedure) Nerve Conduction Studies and Electromyograph
- Nerve Conduction Studies
- 95873 Electrical stimulation for guidance in conjunction with chemodenervation (list separately in addition to code for primary procedure)
- 95905 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 95907 Nerve conduction studies, 1-2 studies
- 95908 Nerve conduction studies, 3-4 studies
- 95909 Nerve conduction studies, 5-6 studies
- 95910 Nerve conduction studies, 7-8 studies
- 95911 Nerve conduction studies, 9-10 studies
- 95912 Nerve conduction studies, 11-12 studies
- 95913 Nerve conduction studies, 13 or more studies
- 95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing
- 95937 Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method
- G0255 Current perception threshold/sensory nerve conduction test, (snct) per limb, any nerve
Billing and Coding Guidelines
- CPT Codes 95860-95866 – Electromyography and Nerve Conduction Tests
- Only one unit of service should be billed
- To bill these codes, extremity muscles innervated by three nerves (e.g., 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
- CPT Code 95869 – Needle electromyography; thoracic paraspinal muscles
- 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.
- 96869 should be used to study thoracic paraspinal muscles between T3 and T11
- One unit can be billed, despite the number of levels studied or whether unilateral or bilateral
- CPT Code 95870 – 95872 95885-95887 (Needle electromyography, other than paraspinal)
- 95870 is used for limited testing of specific muscles during an examination and should be used only when the muscles tested do not fit more appropriately under another CPT code
- 95870 can be billed at one unit per extremity (one limb, arm or leg), when fewer than five muscles are examined
- 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 level tested
- 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 Codes 95900, 95903, 95904 – Nerve Conduction Studies
- 95900, 95903, and/or 95904 are used only once when multiple sites on the same nerve are stimulated or recorded
- To qualify as a study of two or more branches of a given motor, sensory, or mixed nerve, both the stimulating and recording electrodes must be moved to different locations. In this case, it is appropriate to bill for the number of multiple units of CPT codes 95900- 95904 performed
- As most nerves have a contralateral counterpart, bilateral testing is often necessary for comparison purposes. Nerves on each side may be billed separately. In addition, motor CPT code 95900 or 95903, sensory CPT code 95904, and mixed sensory CPT code 95904 studies on an individual nerve may be appropriately billed separately
- 95903 and 95900 may appropriately be billed together for the same patient on the same day when multiple nerves are tested, some with and some without F waves, since, in that case they describe distinct and independent services. However, CPT codes 95903 and 95900 cannot be billed together for the same nerve in a given patient on a given day
- Testing the ulnar nerve at wrist, forearm, below elbow, above elbow, axilla and supraclavicular regions will all be considered as a one-unit test of 95900 or 95904. Different methods of measuring the conduction in the same nerve will not be reimbursed as separate services
Documentation Requirements
- The patient’s medical records must clearly document the medical necessity for the test. Data gathered during NCS should reflect the actual numbers (latency, amplitude, etc.), preferably in a tabular 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.
- 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.
Reasons for Denial
- Electromyography
- Narrative reports alluding to “normal” or abnormal” results without numerical data.
- Descriptions of F-wave without reference to a corresponding motor conduction data; pattern-setting unilateral H-reflex measurements; separate E/M consultation charges without documentation requested from the referral source.
- Screening testing for polyneuropathy (not mononeuropathies) of diabetes or end-stagerenal-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.
- Surface and macro EMGs will not be paid.
- Failure to submit, upon request or when request an informal review, a clinical history indication the need for testing.
- Nerve Conduction Studies
- Narrative reports alluding to “normal” or abnormal” results without numerical data.
- Examination using portable hand-held devices, which are incapable of waveform analysis, will be included in a visit. They will not be paid separately.
- Psychophysical measurements (current, vibration, thermal perceptions) even though they may involve delivery of a stimulus, are not covered.
- Absence of a clinical history, preferable written by the referral source, indicating the need for the test.
- Absence of documentation to support repeated testing on the same beneficiary or testing every beneficiary referred for pain.
- Screening testing for polyneuropathy (not mononeuropathies) of diabetes or end-stagerenal-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.
- Even if two or more methods of testing are used (as orthodromic and antidromic testing) to obtain results from a single nerve, only one unit of charge will be paid unless clear reasons and evident value for performing both studies are documented.
- Segmental testing of a single nerve will not be reimbursed on a multiple unit basis.
- Failure to submit, upon request or when requesting an informal review, a clinical history indication the need for testing.
- 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.
Streamline your coding process and ensure compliance with coding guidelines.
The above guidelines are not exhaustive. With the complexities involved in billing EMG and NCS, relying on an expert medical billing and coding company is a feasible option. An experienced EDX billing service can help physicians submit accurate claims to meet payer requirements, maximize reimbursement, and avoid audit risks.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.