L28834-LCD

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Local Coverage Determination (LCD) for Electromyography and Nerve Conduction Studies (L28834)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28834

LCD Title Electromyography and Nerve Conduction Studies

Contractor's Determination Number A95860

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 01/01/2012 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80

CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1, Part 2, Section

160.23

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.1.3

Indications and Limitations of Coverage and/or Medical Necessity

Electrodiagnostic studies are frequently used to evaluate patients with suspected neuromuscular disorders and include needle electromyography (EMG) and other nerve stimulation tests such as nerve conduction studies (NCS). Electrodiagnostic testing may provide an important means of diagnosing conditions attributable to nerve, muscle, or neuromuscular junction weakness such as myopathies (muscle weakness), radiculopathies (nerve root disease), plexopathies (peripheral neuropathy), neuropathies (nerve disease), neuromuscular junction disorders, and nerve compression syndromes.

Both electromyography and nerve conduction studies are required for a clinical diagnosis of some peripheral nervous system disorders. In such instances when both procedures are needed, they should be performed together. In instances where only one study is to be performed, the rationale should be included in the clinical documentation.

Clinicians use tests to help them with decision making. Test results may help reduce uncertainty in diagnosis or confirm a diagnosis. However, test results may increase uncertainty if the tests poorly discriminate between patients with and patients without a certain disease, if the test results are not consistent with the clinical picture, or if the testing is improperly integrated into the clinical context. The testing must be used in individual patient decision making and the medical record must support a neuromuscular based history and physical exam that preceded the initiation of testing. Population based testing of patients without signs or symptoms to detect occult disease is secondary prevention (screening testing) and not a Medicare benefit for NCS, EMG.

Electromyography (EMG)

EMG is the study and recording of intrinsic electrical properties of skeletal muscles. This is carried out with a needle electrode. Generally, the electrodes are of two types: monopolar or concentric. EMG, when performed, is usually performed in conjunction with NCS. Unlike NCS, however, EMG testing relies on both auditory and visual feedback to the electromyographer. This testing is also invasive in that it requires needle electrode insertion and adjustment at multiple sites, and at anatomically critical sites. The muscles studied will vary depending upon the differential diagnosis and the ongoing synthesis of new information obtained while the test is being performed.

This portion of the electrodiagnostic examination should always be performed by the physician.

Neurogenic disorders are distinguishable from myopathic disorders by a carefully performed EMG. Below is a list of common disorders where an EMG will be helpful in diagnosis:

• Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions.

• Radiculopathy – cervical, lumbosacral.

• Mononeuropathy/polyneuropathy – metabolic, degenerative, hereditary

• Myopathy – including poly-and dermatomyositis, myotonic and congenital myopathies.

• Plexopathy – idiopathic, trauma, infiltration.

• Neuromuscular junction disorders – myasthenia gravis. (Single fiber EMG (95872) is of special value here.)

Nerve Conduction Studies (NCS)

NCS are performed to assess the integrity of, and to diagnose diseases of, the peripheral nervous system. Specifically, they assess the speed (conduction, velocity, and/or latency), size (amplitude), and shape of the response. Pathological findings include conduction slowing, conduction block, no response, and/or low amplitude response. NCS results can assess the degree of demyelination and axon loss in the segments of the nerve studied.

Performance of NCS on the suspected peripheral nerve(s) involves the use of electrodes, one for stimulation and one for recording. Peripheral motor, sensory and mixed testing are often conducted together, and can be followed by an EMG of a muscle in special cases. NCS reports should document the nerves evaluated, the distance

between the stimulation and recording sites, the conduction velocity, latency values, and amplitude. The temperature of the studied limbs may be included.

Although the stimulation of nerves is similar with all NCS, the characteristics of motor, sensory, and mixed NCS are different.

• Motor NCS 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 NCS 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 NCS are performed by applying electrical stimulation near a nerve containing both 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 NCS 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.

A list of examples to help in the localization of an abnormality and in distinguishing one variety of neuropathy form another is given below:

• Focal neuropathies or compressive lesions such as 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, inflammatory, or immune.

• Repetitive nerve stimulation in diagnosis of neuromuscular junction disorders such as myasthenia gravis, myasthenic syndrome.

Limitations

Examination(s) using devices which are incapable of wave-form analysis will be included in an evaluation and management visit and not paid separately. Consistent excessive use of units of testing, repeated testing on the same patient, or testing every patient referred for pain, weakness or paresthesia may become evident on review. In those cases, unless documentation in the patient’s file substantiates the medical necessity of the test(s) performed, claims could be denied for lack of medical necessity. The NCS-EMG performing provider, in addition to the referring provider, is responsible for determination of the appropriateness of a study.

Electrodiagnostic studies are covered when performed by providers of neurology and physiatry services, or other providers who have specialized training and expertise in performing NCS and EMG. They must have a detailed knowledge of neuromuscular diseases and awareness of the influence of age, temperature, and body height on the results. Since these tests may produce anxiety and stress, an exquisite awareness of the patient’s comfort and sensitivity are essential.

The CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf outlines that “reasonable and necessary" services are "ordered and/or furnished by qualified personnel."

A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare.

B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

The performance of EMG/NCS by non-physicians is governed by the scope of practice defined by their state and the appropriate level of supervision described in the Federal Register.

• Codes 95860, 95861, 95863, 95864, 95867, 95868, 95869,95870, 95885, 95886, and 95887 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, 95905, 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 certification under the general supervision of a physician.

It would be expected that the individual interpreting the test is also supervising the test, as part of the supervision involves evaluating both the quality and extent of testing performed.

The number of units per code and frequency of individual patient testing are addressed in the utilization section.

Sensory Nerve Conduction Threshold Test (sNCT) is not covered by Medicare. Effective April 1, 2004, based on a reconsideration of current Medicare policy for sNCT, CMS concludes that the use of any type of sNCT device (e.g., "current output" type device used to perform current perception threshold (CPT), pain perception threshold (PPT), or pain tolerance threshold (PTT) testing or "voltage input" type device used for voltage-nerve conduction threshold (v-NCT) testing) to diagnose sensory neuropathies or radiculopathies in Medicare beneficiaries is not reasonable and necessary.

All uses of sNCT to diagnose sensory neuropathies or radiculopathies are noncovered.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only)

013x Hospital Outpatient

021x Skilled Nursing - Inpatient (Including Medicare Part A)

022x Skilled Nursing - Inpatient (Medicare Part B only)

023x Skilled Nursing - Outpatient

071x Clinic - Rural Health

075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)

085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

092X Other Diagnostic Services - General Classification

CPT/HCPCS Codes

Electromyography

95860 NEEDLE ELECTROMYOGRAPHY; 1 EXTREMITY WITH OR WITHOUT RELATED PARASPINAL AREAS

95861 NEEDLE ELECTROMYOGRAPHY; 2 EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS

95863 NEEDLE ELECTROMYOGRAPHY; 3 EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS

95864 NEEDLE ELECTROMYOGRAPHY; 4 EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS

95867 NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLE(S), UNILATERAL

95868 NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLES, BILATERAL

95869 NEEDLE ELECTROMYOGRAPHY; THORACIC PARASPINAL MUSCLES (EXCLUDING T1 OR T12)

NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY OF MUSCLES IN 1 EXTREMITY OR NON-LIMB (AXIAL) 95870 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

NEEDLE ELECTROMYOGRAPHY, EACH EXTREMITY, WITH RELATED PARASPINAL AREAS, WHEN

95885 PERFORMED, DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY; LIMITED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

NEEDLE ELECTROMYOGRAPHY, EACH EXTREMITY, WITH RELATED PARASPINAL AREAS, WHEN

95886 PERFORMED, DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY; 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)

NEEDLE ELECTROMYOGRAPHY, NON-EXTREMITY (CRANIAL NERVE SUPPLIED OR AXIAL) MUSCLE(S) DONE 95887 WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY (LIST SEPARATELY IN

ADDITION TO CODE FOR PRIMARY PROCEDURE)

Nerve Conduction Studies

95900 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, WITHOUT F- WAVE STUDY

95903 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, WITH F-WAVE STUDY

95904 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; SENSORY MOTOR AND/OR SENSORY NERVE CONDUCTION, USING PRECONFIGURED ELECTRODE ARRAY(S),

95905 AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH LIMB, INCLUDES F-WAVE STUDY WHEN PERFORMED,

WITH INTERPRETATION AND REPORT

95934 H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD GASTROCNEMIUS/SOLEUS MUSCLE

95936 H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD MUSCLE OTHER THAN GASTROCNEMIUS/SOLEUS MUSCLE

95937 NEUROMUSCULAR JUNCTION TESTING (REPETITIVE STIMULATION, PAIRED STIMULI), EACH NERVE, ANY 1 METHOD

ICD-9 Codes that Support Medical Necessity

192.2 MALIGNANT NEOPLASM OF SPINAL CORD

192.3 MALIGNANT NEOPLASM OF SPINAL MENINGES

198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

198.4 SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM

250.60 - 250.63 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

265.1 OTHER AND UNSPECIFIED MANIFESTATIONS OF THIAMINE DEFICIENCY

269.1 DEFICIENCY OF OTHER VITAMINS

335.0 - 335.9 WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED

336.0 - 336.9 SYRINGOMYELIA AND SYRINGOBULBIA - UNSPECIFIED DISEASE OF SPINAL CORD

337.1 IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY, UNSPECIFIED

337.2 CAROTID SINUS SYNDROME

337.09 OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY

337.20 - 337.29 REFLEX SYMPATHETIC DYSTROPHY UNSPECIFIED - REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE

337.3 AUTONOMIC DYSREFLEXIA

340 MULTIPLE SCLEROSIS

341.0 - 341.9 NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED

344.00 - 344.9 QUADRIPLEGIA UNSPECIFIED - PARALYSIS UNSPECIFIED

350.1 - 350.9 TRIGEMINAL NEURALGIA - TRIGEMINAL NERVE DISORDER UNSPECIFIED

351.0 BELL'S PALSY

351.8 OTHER FACIAL NERVE DISORDERS

352.3 DISORDERS OF PNEUMOGASTRIC (10TH) NERVE

352.4 DISORDERS OF ACCESSORY (11TH) NERVE

352.5 DISORDERS OF HYPOGLOSSAL (12TH) NERVE

352.6 MULTIPLE CRANIAL NERVE PALSIES

353.1 BRACHIAL PLEXUS LESIONS

353.2 LUMBOSACRAL PLEXUS LESIONS

353.3 CERVICAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.4 THORACIC ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.5 LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.6 NEURALGIC AMYOTROPHY

354.0 - 354.9 CARPAL TUNNEL SYNDROME - MONONEURITIS OF UPPER LIMB UNSPECIFIED

355.0 - 355.9 LESION OF SCIATIC NERVE - MONONEURITIS OF UNSPECIFIED SITE

356.0 - 356.9 HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

357.0 - 357.9 ACUTE INFECTIVE POLYNEURITIS - UNSPECIFIED INFLAMMATORY AND TOXIC NEUROPATHIES

358.00 - 358.01 MYASTHENIA GRAVIS WITHOUT (ACUTE) EXACERBATION - MYASTHENIA GRAVIS WITH (ACUTE) EXACERBATION

358.1* MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE

359.0 - 359.9 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY - MYOPATHY UNSPECIFIED

368.2 DIPLOPIA

378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS

710.4 POLYMYOSITIS

721.0 - 721.91 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY - SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY

722.4 DEGENERATION OF CERVICAL INTERVERTEBRAL DISC

722.51 - 722.52 DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRAL DISC - DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC

722.80 - 722.83 POSTLAMINECTOMY SYNDROME OF UNSPECIFIED REGION - POSTLAMINECTOMY SYNDROME OF LUMBAR REGION

723.1 CERVICALGIA

723.4 BRACHIAL NEURITIS OR RADICULITIS NOS

724.2 LUMBAGO

724.3 SCIATICA

724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED

728.2 MUSCULAR WASTING AND DISUSE ATROPHY NOT ELSEWHERE CLASSIFIED

728.85 SPASM OF MUSCLE

728.87 MUSCLE WEAKNESS (GENERALIZED)

729.5 PAIN IN LIMB

729.71 NONTRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY

729.72 NONTRAUMATIC COMPARTMENT SYNDROME OF LOWER EXTREMITY

736.05 WRIST DROP (ACQUIRED)

736.79 OTHER ACQUIRED DEFORMITIES OF ANKLE AND FOOT

780.79 OTHER MALAISE AND FATIGUE

781.2 ABNORMALITY OF GAIT

781.3 LACK OF COORDINATION

781.4 TRANSIENT PARALYSIS OF LIMB

782.0 DISTURBANCE OF SKIN SENSATION

787.20 - 787.29 DYSPHAGIA, UNSPECIFIED - OTHER DYSPHAGIA

952.00 - 952.09 C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED - C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.10 - 952.19 T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED - T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.2 LUMBAR SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.3 SACRAL SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.4 CAUDA EQUINA SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.8 MULTIPLE SITES OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

* 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.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

The patient’s medical record must contain documentation that fully supports the medical necessity (and frequency) for EMG and NCS as covered by Medicare (see the “Indications and Limitations of Coverage and/or Medical Necessity” section). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, and should be available to Medicare upon request. The evaluation and management service supporting the medical necessity of nerve conduction testing and/or electromyography should contain a focused neuromuscular history and examination, directed at the CNS and/or nerve roots, and/or peripheral nerves, and/or neuromuscular junction and/or muscles in question.

If the provider of electrodiagnostic studies is other than the ordering/referring physician/nonphysician practitioner, the provider of the service must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the studies.

A clinical history from the referral source must clearly document the need for each EMG and NCS test. Data gathered during NCS should be available and reflect the actual numbers (latency, amplitude, etc.), preferably in a tabular (not narrative) format. The reason for referral and a clear diagnostic impression are required for each study.

Appendices

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Segmental testing of a single nerve represents a single study. For example, tests 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 contained in the “Coding Guidelines” section, 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.

Sources of Information and Basis for Decision

American Association of Neuromuscular & Electrodiagnostic Medicine. (2006). Proper performance and interpretation of electrodiagnostic studies. Muscle Nerve 33:436-439.

Jablecki, C., Busis, N., Brandstater, M., Krivickas, L., Miller, R., Robinton, J. (2005). Reporting the results of needle EMG and nerve conduction studies an educational report. AANEM Practice Topic. Muscle & Nerve.

North American Spine Society. (2003). Electromyogram and nerve conduction study. Retrieved November 9, 2006, from http://www.spine.org/articles/emg_test.cfm.

Mallik, A., & Weir, A. (2005). Nerve conduction studies: essentials and pitfalls in practice. Journal of Neurology Neurosurgery and Psychiatry, 76:ii23-ii31.

Morse, J. (2006). NC-stat® System, Neuro Metric® Inc. (Nerve Conduction Testing System). Technology Assessment. Department of Labor and Industries.

Social Security Act (Sec. 1861(s)(2) and (Sec. 1861(s)(3)

TeleEMG. (2006). Nerve conduction studies and Needle examinations. Electronic EMG Manual. Retrieved November 15, 2006, from http://www.teleemg.com/new/jbr010.htm and http://www.teleemg.com/new/jbr100.htm.

Other Medicare Carriers’ LCDs.

Other Private Insurers’ practice guidelines

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with the advisory groups, which includes representatives from Neurology and Physical Medicine and Rehabilitation.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/2010

Revision History Number 3

Revision History Explanation Revision Number:3 Start Date of Comment Period:

Start Date of Notice Period:01/01/2012 Revised Effective Date:01/01/2012

LCR A2012-009

December 2011 Connection

Explanation of Revision: Annual 2012 HCPCS Update. Added CPT codes 95885, 95886, and 95887. The effective date of this revision is based on date of service.

Revision Number2

Start Date of Comment Period:N/A Start Date of Notice Period:07/01/2011 Revised Effective Date:06/14/2011

LCR A2011-061

June 2011 Connection

Explanation of Revision: Based on an outside request to clarify our current training statement outlined in this

LCD, language under the “Limitations” section of the LCD has been deleted and replaced with a revised statement regarding the qualification and training. Revisions will be effective based on process date.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2010 Revised Effective Date: 01/01/2010

LCR A2010- 008

December 2009 Bulletin

Explanation of Revision: Annual 2010 HCPCS Update. Added CPT code 95905. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28834) replaces LCD L885 as the policy in notice. This document (L28834) is effective on 02/16/2009.

Updated references under "CMS National Coverage Policy" section, and added CMS non-coverage information for sNCT under the "Limitations" section.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.

11/15/2009 - The description for CPT/HCPCS code 95860 was changed in group 1 11/15/2009 - The description for CPT/HCPCS code 95870 was changed in group 1 11/15/2009 - The description for CPT/HCPCS code 95937 was changed in group 2

8/1/2010 - The description for Bill Type Code 12 was changed 8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 71 was changed 8/1/2010 - The description for Bill Type Code 75 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0920 was changed 8/1/2010 - The description for Revenue code 0921 was changed 8/1/2010 - The description for Revenue code 0922 was changed 8/1/2010 - The description for Revenue code 0923 was changed 8/1/2010 - The description for Revenue code 0924 was changed

8/1/2010 - The description for Revenue code 0925 was changed 8/1/2010 - The description for Revenue code 0929 was changed

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

95860 descriptor was changed in Group 1 95861 descriptor was changed in Group 1 95863 descriptor was changed in Group 1 95864 descriptor was changed in Group 1 95869 descriptor was changed in Group 1 95870 descriptor was changed in Group 1 95872 descriptor was changed in Group 1

Reason for Change