Neurology & Pain Management Coding Alert

Neurologists regularly provide electromyography (EMG) testing (95860-95872) to help diagnose a variety of conditions including carpal tunnel syndrome (CTS), muscular dystrophy and peripheral neuropathy. Although these codes are billed often, many providers still have difficulty in receiving proper reimbursement. Problems may arise because insurers reject the tests as medically unnecessary. In other cases, the provider may be unsure how many muscles must be studied per limb to report the EMG codes, or if it is appropriate to report a limited study of specific muscles multiple times for each muscle. Fortunately, the American Association of Electrodiagnostic Medicine (AAEM) and Medicare provide information that can aid in dealing with these challenges.

Needle EMG is the recording and study of electrical activity of muscle using a needle electrode, says Steven W. Dibert, MD, a neurologist at the Neuroscience and Spine Center in Gastonia, N.C., and a member of the board of directors of the American Society of Neuroimaging and the board of the American Academy of Neurology/Neuroimaging Section. Specifically, EMGs test the electrical activity of skeletal muscle. The tests detect disorders affecting the muscles, but can also diagnose  problems caused by other diseases, such as nerve dysfunction.
 
To perform an EMG, the neurologist places a needle electrode into skeletal muscle and measures muscle response at rest, during mild voluntary contraction, and during maximal contraction, Dibert says. Results are displayed on an oscilloscope as an electrical waveform. An amplifier is also used so the electrical activity can be heard as well as seen. Applicable codes include:

95860 needle electromyography, one extremity with or without related paraspinal areas

95861 two extremities

95863 three extremities

95864 four extremities

95867 cranial nerve supplied muscles, unilateral

95868 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.

Note: Code 95875 (ischemic limb exercise test with serial specimen[s] acquisition for muscle metabolite[s]) was revised in 2002 and no longer specifies "electromyography." The new definition more accurately reflects current clinical practice. Also, a "surface" EMG (95999, unlisted neurological or neuromuscular diagnostic procedure) that uses a probe that is passed over the surface of the skin to measure electrical muscle activity is not the same as a conventional EMG. This method of EMG testing is considered investigational and is not covered by Medicare and most private payers.
 
The neurologist documents and interprets both normal and abnormal findings discovered during the study. Dibert advises that the report should indicate the muscles tested (number and location), the presence and type of spontaneous activity, and the characteristics of the voluntary unit potentials. Based on this information or with results from other diagnostic tests such as nerve conduction studies the neurologist makes a final diagnosis, which may be a symptom diagnosis or a diagnosis of normal.

Begin with an Accepted Diagnosis

As with all diagnostic testing, EMGs must be supported by documented medical necessity, says Tiffany Eggers, JD, MPA, policy director and legislative counsel for the American Association of Electrodiagnostic Medicine. EMGs are considered screening (and therefore not payable) in the absence of signs and symptoms that indicate medical necessity. Normally, the neurologist will arrive at a differential diagnosis based on these signs and symptoms. A final diagnosis can be offered only after testing. Neurologists should not use an unconfirmed or "rule-out" diagnosis to justify EMG testing.
 
Payers do not observe standards concerning which ICD-9 codes prove medical necessity for EMG testing. Typically acceptable diagnoses include postherpetic polyneuropathy (053.13), various neoplasms (192.0-237.6), diabetes (250.6-250.63), spinocerebellar disease (334-334.9), diseases of the spinal cord (335-336.9), multiple sclerosis (340), trigeminal neuralgia (350.1), and pain in limb (729.5). Although payers may allow several hundred diagnoses to support EMGs, not every diagnosis will support all EMG codes in every case. The best strategy is to ask individual payers for a list of diagnoses they accept.
 
In all cases, the number of limbs tested should be the minimum needed to confirm the differential diagnosis (e.g., one limb for unilateral CTS symptoms), Eggers says. The AAEM provides a table of the reasonable maximum number of studies per diagnostic category (EMGs, nerve conduction studies, etc.) necessary for a physician to confirm a diagnosis in 90 percent of patients. The association notes, however, "The appropriate number of studies to be performed should be left to the judgment of the physician performing the electrodiagnostic evaluation." In the few cases that 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." According to the AAEM, such documentation should explain what other differential diagnostic problems needed to be ruled out in that particular situation.
 
Note: To view the table, which has been newly updated for 2002, visit the AAEM Web site: www.aaem.net/position_statements/recommended_policy_6.htm.

CMS published its recommendations for EMG billing in the Oct. 31, 1997, Federal Register (Vol. 62, No. 211, p. 59090). These guidelines cover common questions regarding EMGs, including how many muscles need to be studied per limb to use the limb EMG codes and whether one can bill codes for limited study of specific muscles multiple times for each muscle, as follows:
 
95860-95864: To report these codes, the neurologist must evaluate extremity muscles innervated by three nerves (e.g., radial, ulnar, median, tibial, peroneal or femoral but not sub-branches) or four spinal levels, with a minimum of five muscles studied per limb. Do not report paraspinals separately with 95860-95864 unless studying those between T3-T11, in which case 95869 is applicable.
 
These codes are commonly used during testing for CTS. For example, a patient with CTS symptoms in the left wrist arrives for a scheduled EMG. If at least five muscles innervated by the radial, ulnar and median nerves are studied and documented, use 95860. If the patient presents with bilateral symptoms, and the procedure for the left wrist is repeated on the right, the correct code is 95861. If fewer than five muscles are documented, 95870, not 95860-95864, is appropriate.
 
95867-95868: These codes are to report needle examination of one or more muscles supplied by cranial nerves unilaterally (95867) or bilaterally (95868). Codes 95867 and 95868 should not be reported together, nor should modifier -50 (bilateral procedure) be attached to 95868.
 
For instance, 95867 may be used to diagnose possible motor neuron disease, 335.2. The neurologist studies the motor neurons on a single side of the brain, which, if degenerated, can lead to weakness and wasting of muscles. The same procedure may be performed bilaterally to diagnose Bell's palsy, 351.0. In this case, a "control" must be obtained to compare with the affected side of the body. Such a procedure would be reported with 95868.
 
95869: This code is for exclusive study of thoracic paraspinal muscles. Report only one unit regardless of the number of levels studied or whether the test was performed unilaterally or bilaterally. As explained above, 95869 cannot be reported with 95860-95864 if only the T1 and/or T2 levels are studied with an upper extremity.
 
This test might be used, for example, to diagnose suspected thoracic radiculopathy (724.4) linked to cancer or diabetes.
 
95870: Neurologists may bill one unit of 95870 per extremity if fewer than five muscles are tested, e.g., exams confined to distal muscles such as intrinsic foot or hand muscles. As previously mentioned, this code may apply when testing four or fewer muscles in a patient with suspected CTS.
 
Also use this code for muscles on the thorax or abdomen (unilateral or bilateral). Report a single unit for studying cervical or lumbar paraspinal muscles (unilateral or bilateral) regardless of the number of levels tested. Do not report 95870 when the paraspinal muscles corresponding to an extremity are tested, i.e., when 95860-95864 are also reported.
 
95872: Single fiber electromyography uses a special needle electrode to record and identify action potentials from individual muscle fibers. It is the most sensitive clinical test of neuromuscular transmission. Jitter and fiber density may be measured in one or more muscles depending on the condition to be evaluated and the results of testing. Increased jitter is a nonspecific sign of abnormal neuromuscular transmission and can be seen in many motor-unit diseases. Normal jitter in a weak muscle excludes abnormal neuromuscular transmission as the cause of weakness. The test is effective in diagnosing diseases such as myasthenia gravis, 358.0.
 
Needle EMG should be performed in at least one muscle (as a control) before attributing pathologic jitter or blocking to a neuromuscular transmission disorder.

Some insurers have required that a hard copy of EMG results be included with all EMG claims as a condition of reimbursement. The AAEM has taken a strong position against such requirements, reasoning, "Needle EMG studies are interpreted in real time, as they are being performed. Most electromyographic machines are unable to permanently copy the sounds produced during needle EMG testing. Also, it is difficult and expensive to permanently copy needle EMG oscilloscope tracings. For this reason, these tracings should not be required." Also, the association reasoned that such recordings would add no useful information to EMG claims.
 
If your insurer requires a hard copy of EMG reports, challenge the decision. Cite the AAEM's position statement (available at http://www.aaem.net/position_statements.htm) as evidence that such reports are unnecessary. If this fails, you should appeal to the insurer's medical director.