LCD/NCD Portal

L29280 SOMATOSENSORY TESTING

 

 

01/01/2012

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• Medicare will consider the use of short-latency somatosensory evoked potentials to be medically reasonable and necessary:

o to assist in the diagnosis of certain neuropathologic states (as described below) in order to provide information for treatment and for intraoperative testing during spinal surgeries in which there is risk of additional nerve or spinal cord injury.

• SEPs are used to evaluate the more proximal segments of nerves and the integrity of the central somatosensory pathways when slowing of conduction through the brain and/or brainstem, spinal cord, and/or peripheral nerves is suspected.

o This would include conditions such as

 multiple sclerosis,

 cervical spondylosis with myelopathy,

 coma,

 spinal cord trauma,

 hereditary and idiopathic peripheral neuropathies,

 inflammatory and toxic neuropathies,

 myoclonus,

 Friedreich’s ataxia,

 Syringomyelia,

 spinal cord tumors,

 spinal stenosis and

 Other conditions where there is spinal cord compression.

 

 

CPT/HCPCS Codes

 

95925 SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER LIMBS

95926 SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN LOWER LIMBS

95927 SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN THE TRUNK OR HEAD

95938 SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER AND LOWER LIMBS

 

 

ICD-9 Codes that Support Medical Necessity

 

192.2 MALIGNANT NEOPLASM OF SPINAL CORD

198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

225.3 BENIGN NEOPLASM OF SPINAL CORD

237.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD

250.61 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.62 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.63 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

333.2 MYOCLONUS

334.0 FRIEDREICH'S ATAXIA

334.1 HEREDITARY SPASTIC PARAPLEGIA

336.0 SYRINGOMYELIA AND SYRINGOBULBIA

336.9 UNSPECIFIED DISEASE OF SPINAL CORD

340 MULTIPLE SCLEROSIS

356.0 HEREDITARY PERIPHERAL NEUROPATHY

356.1 PERONEAL MUSCULAR ATROPHY

356.2 HEREDITARY SENSORY NEUROPATHY

356.3 REFSUM'S DISEASE

356.4 IDIOPATHIC PROGRESSIVE POLYNEUROPATHY

356.8 OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

356.9 UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

357.0 ACUTE INFECTIVE POLYNEURITIS

357.1 POLYNEUROPATHY IN COLLAGEN VASCULAR DISEASE

357.2 POLYNEUROPATHY IN DIABETES

357.3 POLYNEUROPATHY IN MALIGNANT DISEASE

357.4 POLYNEUROPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

357.5 ALCOHOLIC POLYNEUROPATHY

357.6 POLYNEUROPATHY DUE TO DRUGS

357.7 POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS

357.81 CHRONIC INFLAMMATORY DEMYELINATING POLYNEURITIS

357.82 CRITICAL ILLNESS POLYNEUROPATHY

357.89 OTHER INFLAMMATORY AND TOXIC NEUROPATHY

357.9 UNSPECIFIED INFLAMMATORY AND TOXIC NEUROPATHIES

721.1 CERVICAL SPONDYLOSIS WITH MYELOPATHY

723.0 SPINAL STENOSIS IN CERVICAL REGION

724.02 SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION

724.03 SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

780.01 COMA

806.00 CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY

806.01 CLOSED FRACTURE OF C1-C4 LEVEL WITH COMPLETE LESION OF CORD

806.02 CLOSED FRACTURE OF C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME

806.03 CLOSED FRACTURE OF C1-C4 LEVEL WITH CENTRAL CORD SYNDROME

806.04 CLOSED FRACTURE OF C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.05 CLOSED FRACTURE OF C5-C7 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY

806.06 CLOSED FRACTURE OF C5-C7 LEVEL WITH COMPLETE LESION OF CORD

806.07 CLOSED FRACTURE OF C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME

806.08 CLOSED FRACTURE OF C5-C7 LEVEL WITH CENTRAL CORD SYNDROME

806.09 CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.10 OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY

806.11 OPEN FRACTURE OF C1-C4 LEVEL WITH COMPLETE LESION OF CORD

806.12 OPEN FRACTURE OF C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME

806.13 OPEN FRACTURE OF C1-C4 LEVEL WITH CENTRAL CORD SYNDROME

806.14 OPEN FRACTURE OF C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.15 OPEN FRACTURE OF C5-C7 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY

806.16 OPEN FRACTURE OF C5-C7 LEVEL WITH COMPLETE LESION OF CORD

806.17 OPEN FRACTURE OF C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME

806.18 OPEN FRACTURE OF C5-C7 LEVEL WITH CENTRAL CORD SYNDROME

806.19 OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.20 CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY

806.21 CLOSED FRACTURE OF T1-T6 LEVEL WITH COMPLETE LESION OF CORD

806.22 CLOSED FRACTURE OF T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME

806.23 CLOSED FRACTURE OF T1-T6 LEVEL WITH CENTRAL CORD SYNDROME

806.24 CLOSED FRACTURE OF T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.25 CLOSED FRACTURE OF T7-T12 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY

806.26 CLOSED FRACTURE OF T7-T12 LEVEL WITH COMPLETE LESION OF CORD

806.27 CLOSED FRACTURE OF T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME

806.28 CLOSED FRACTURE OF T7-T12 LEVEL WITH CENTRAL CORD SYNDROME

806.29 CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.30 OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY

806.31 OPEN FRACTURE OF T1-T6 LEVEL WITH COMPLETE LESION OF CORD

806.32 OPEN FRACTURE OF T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME

806.33 OPEN FRACTURE OF T1-T6 LEVEL WITH CENTRAL CORD SYNDROME

806.34 OPEN FRACTURE OF T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.35 OPEN FRACTURE OF T7-T12 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY

806.36 OPEN FRACTURE OF T7-T12 LEVEL WITH COMPLETE LESION OF CORD

806.37 OPEN FRACTURE OF T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME

806.38 OPEN FRACTURE OF T7-T12 LEVEL WITH CENTRAL CORD SYNDROME

806.39 OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.4 CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY

806.5 OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY

 

 

Documentation Requirements

 

• Medical record documentation maintained by the performing physician must clearly indicate the medical necessity of the service being billed.

o There should be evidence in the medical record that the test results were noted and influenced or contributed to the patient’s course of treatment.

o In addition, documentation that the service was performed must be included in the patient’s medical record.

o This documentation should include a hard copy computer generated recording of the test results along with the physician’s interpretation.

o The physician’s SEP report should note which nerves were tested, latencies at various testing points, and an evaluation of whether the resulting values are normal or abnormal.

o This information is normally found in the office/progress notes, hospital records, and/or procedure notes.

• If the provider of somatosensory testing 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.

• Documentation should support the criteria for coverage as set forth in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the policy.

• SEP studies are covered when performed by providers of neurology services or other providers who have specialized training and expertise in performing and interpreting this test.

o Such training should include adequate educational experience in the following:

 The influences of stimulus parameters and other experimental variables on the responses that are recorded.

 Existing knowledge of the anatomic structures and neurophysiologic events underlying the generation of evoked potentials.

 The clinical significance and pathologic correlates of dysfunctional neural pathways demonstrated by evoked potentials alterations.

 Relevant normative data and statistics.

• Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty.

o If this skill has been acquired as continuing medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit.

Utilization Guidelines

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

o When services are performed in excess of established parameters, they may be subject to review for medical necessity.

• SEP studies are appropriate only when a detailed clinical history and neurologic examination and imaging studies, and EMG/Nerve Conduction studies have failed to provide adequate information for a specific treatment plan.

Treatment Logic

• Short-latency somatosensory evoked potentials (SEPs) represent early electrophysiologic responses of the somatosensory pathways to stimulation.

• Somatosensory testing involves the application of multiple brief electrical stimuli over peripheral nerves (e.g., the median, peroneal, and tibial nerves) and recording the evoked potentials over proximal portions of the nerves stimulated, the plexus, spine and/or scalp.

• These readings are then averaged by a computer and can be traced and recorded in the form of waveforms.

• A physician trained in interpreting clinical evoked potential studies then interprets these waveforms.

• The waveforms obtained should be described and the peak latencies, interpeak intervals (when appropriate), and amplitudes of the significant components detailed.

• The nerves most commonly stimulated are the median nerve at the wrist for testing in the upper extremity, and the common peroneal nerve (CPN) at the knee and the posterior tibial nerve at the ankle for the lower extremity.

 

 

Sources of Information and Basis for Decision

 

American Association of Electrodiagnostic Medicine (AAEM). (2006). Recommended policy for electrodiagnostic medicine. Retrieved December 5, 2006 from http://www.aanem.org/practiceissues/recPolicy/recommended_policy_1.cfm

 

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

 

Goetz, C.G. (2003). Textbook of Clinical Neurology, 2nd ed. Chicago: Saunders.

 

Legatt, A. (2006). Somatosensory Evoked Potentials: General Principles. Retrieved December 4, 2006, from http://www.emedicine.com/neuro/topic640.htm

 

01/01/2012

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD SOMATOSENSORY TESTING