Neurology & Pain Management Coding Alert

Question: I'm confused about using 95860 versus 95870 for EMG testing of CTS. If the physician tests five muscles in one limb and two muscles in the second limb, should I report 95860 for the first limb and 95870 with modifier -59 for the second, or should I report 95861 for two extremities? Also, does it make a difference if one extremity was done as a comparison study, or must there be symptoms in the second extremity to report the test?

Arizona Subscriber

Answer: If the physician uses electromyography (EMG) for carpal tunnel syndrome (CTS), testing five muscles in one limb and two in the other, you are correct to report 95860 (Needle electromyography; one extremity with or without related paraspinal areas) for the first limb and 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) with modifier -59 (Distinct procedural service) for the second limb, even if the neurologist tested the second limb to establish a baseline value, that is, for comparison. You may further differentiate the separate nature of the procedures by appending HCPCS level II modifiers -LT (Left side) and -RT (Right side). For example, if the physician tests five muscles on the left arm and two on the right, report 95860-LT and 95870-59-RT. This will explicitly alert the payer that the tests occurred on different limbs and will help prevent denials based on the "bundling" of 95870 into 95860.

According to CMS regulations, you must study a minimum of five muscles in each limb to report EMG codes 95860-95864. In the case above, because the physician tested only two muscles in the second limb, 95861 ( two extremities with or without related paraspinal areas) is not appropriate. If the physician had tested at least five muscles in each arm, however, 95861 would be appropriate.