Neurology & Pain Management Coding Alert

According to CMS guidelines posted in the Oct. 31, 1997, Federal Register (Vol. 62, No. 211, p. 59090), to report 95860-95864 the neurologist must evaluate extremity muscles innervated by three nerves (for example, radial, ulnar, median, tibial, peroneal or femoral but not sub branches) or four spinal levels, with a minimum of five muscles studies per limb. For fewer than five muscles, you should report 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) rather than 95860-95864 (see below).

The "related paraspinal areas" mentioned in code descriptors 95860-95864 include all paraspinals except those of the thoracic (T3-T11) region, Busis says. Therefore, you should not report paraspinal-area testing separately with 95860-95864 unless the physician studies those between T3-T11, in which case 95869 (Needle electromyography; thoracic paraspinal muscles [excluding T1 or T12]) is applicable (see below). Note, in addition, that because these codes specify the number of limbs tested, you should not use modifier -50 (Bilateral procedure) with 95860-95864.

For example, a patient presents with pain in the right leg (729.5, Pain in limb). The neurologist performs EMG on five muscles of the affected leg. In this case, the appropriate code is 95860. If the physician also conducts an EMG on the symptom-free leg to provide a comparison, she may report 95861 (no modifiers are necessary), as long as she meets the minimum testing requirements (five muscles innervated by three nerves each) for each leg.

In a second example, a patient presents with indications of bilateral carpal tunnel syndrome, or CTS (354.0), and the neurologist conducts EMG testing on each arm. Here again assuming the physician performs and documents all minimum requirements 95861 is appropriate.

When assigning 95860-95864, report only the minimum number of limbs required to confirm the differential diagnosis (for example, one limb for unilateral CTS symptoms). The American Association of Electrodiagnostic Medicine (AAEM) has constructed a table that lists the reasonable maximum number of studies necessary for a physician to confirm a diagnosis in 90 percent of patients (see "Know Your Limits: Recognize Use and Frequency Guidelines for EDX Testing" in Neurology Coding Alert, October 2002), which Medicare and other payers closely observe. "You can't test and bill indiscriminately," says Tiffany Schmidt, JD, AAEM's policy director.

The AAEM's recommended policy goes on to say, 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." Schmidt says that such documentation should explain what other differential diagnostic problems needed to be ruled out in that particular situation.

The next two codes in this series describe EMG study of muscles supplied by the cranial nerve, either unilaterally or bilaterally, respectively:

Because a bilateral procedure is inclusive of a unilateral procedure, you should not report 95867 and 95868 at the same time. And do not attach modifier -50 to either 95867 (because a bilateral code already exists) or 95868 (because it already specifies "bilateral").

As an example of proper use, the physician may employ 95867 to diagnose possible motor neuron disease (335.2x). The neurologist studies the motor neurons on one side of the face to evaluate possible weakness and wasting of muscles. He may repeat the procedure on the other side to provide a comparison to diagnose Bell's palsy (351.0) or other disorders. In this case, the proper code is 95868.

As discussed above, you should report 95869 (Needle electromyography; thoracic paraspinal muscles [excluding T1 or T12]) with 95860-95864 for study of thoracic paraspinal muscles, levels T3-T11. If the physician studies only the T1 and/or T2 levels, you may not report 95869 in addition to 95860-95864. Report only one unit of 95869, regardless of the number of levels studied or whether the neurologist tested unilaterally or bilaterally. You might use EMG in this case to diagnose suspected thoracic radicu-lopathy (724.4) linked to cancer, diabetes or other conditions.

When testing fewer than five muscles per extremity (as required for 95860-95864), choose 95870. This may occur during exams confined to distal muscles, such as intrinsic muscles of the hand or foot, or when testing four or fewer muscles in a patient with suspected CTS. For example, you may examine five muscles in one limb and only three in the other. In this case, the correct coding is 95860 and 95870.

You may also report 95870 for EMG testing of muscles on the thorax or abdomen (unilateral or bilateral). When studying cervical or lumbar paraspinal muscles (unilateral or bilateral), claim only a single unit of 95870 regardless of the number of levels tested. In addition, do not report 95870 when the neurologist tests the paraspinal muscles corresponding to an extremity (for example, when also billing 95860-95864) because this would constitute double-billing.

Single-fiber EMG as described by 95872 (Needle electromyography using single-fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied) uses a special needle electrode to record and identify action potentials from individual muscle fibers, and as such is the most sensitive clinical test of neuromuscular transmission. The physician may measure jitter and fiber density in one or more muscles, depending on the condition he or she is evaluating and the results of testing. Increased jitter is a nonspecific sign of abnormal neuromuscular transmission seen in many motor unit diseases.

So-called "surface" EMG, in which a probe is passed over the surface of the skin to measure electrical muscle  activity, is not described by a specific CPT code. Therefore, you should report it using 95999 (Unlisted neurological or neuromuscular diagnostic procedure). Medicare and many private payers consider surface EMG to be an investigational procedure and therefore will not reimburse for it.