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Clinical Policy Title: Electrodiagnostic studies — electromyography and nerve

conduction studies

Clinical Policy Number: 09.01.04

Effective Date: June 1, 2014

Initial Review Date: January 15, 2014

Most Recent Review Date: March 16, 2016

Next Review Date: March 2017

Related policies:

None.

ABOUT THIS POLICY: Keystone First has developed clinical policies to assist with making coverage determinations. Keystone First’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by Keystone First when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Keystone First’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Keystone First’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Keystone First will update its clinical policies as necessary. Keystone First’s clinical policies are not guarantees of payment.

Coverage policy Keystone First considers the use of nerve conduction studies (NCSs), when paired with needle electromyography (NEMG), to be clinically proven and, therefore, medically necessary when the following criteria are met:

Must be performed by a primary care provider (PCP) properly trained in the fields of neurology and/or physiatry, or a PCP who has specific training and expertise in electrophysiologic studies.

Consideration of appropriate diagnosis as listed by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) (see attached codes).

Policy contains:

Needle electromyography (NEMG).

Surface electromyography (SEMG).

Nerve conduction study (NCS).

NC-stat® System.

NK Pressure-Specified Sensory Device™.

Quantitative sensory testing (QST).

NeuroQuick, Neuropad®.

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Keystone First considers the use of the electro-diagnostic tools listed below to be investigational and, therefore, not medically necessary:

When an NCS is performed in the absence of an NEMG.

When the diagnoses listed by the AANEM are not included on the claim.

When non-standard diagnostic modalities, such as surface electromyography (SEMG), the NC-stat® System, quantitative sensory testing (QST) for lower extremity peripheral neuropathy, NeuroQuick, Neuropad®, or the NK Pressure-Specified Sensory Device™ are employed.

* Refer to InterQual for medical review and decision tree. Limitations: All other uses of electro diagnostic modalities, electromyography (EMG), and NCSs are not medically necessary. Note: The following CPT/HCPCS codes are not listed in the Pennsylvania Medicaid fee schedule: 95905 - Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F- wave study when performed, with interpretation and report; G0255 - Current perception threshold/sensory nerve conduction test (SNCT), per limb, any nerve [when specified as other portable automated nerve conduction testing] S3900 - Surface electromyography Alternative covered services: NEMGs and needle (near-placed) nerve conduction velocity (NCV) tests; imaging studies; PCP office visits.

Background Diagnosis of neuromuscular disorders is often difficult. Conditions impacting the peripheral nervous system (PNS), muscles, motor cells of the spinal cord, or the neuromuscular junctions may have similar presentations. The conditions within this spectrum may range from amyotrophic lateral sclerosis (ALS), carpal tunnel syndrome, multiple sclerosis (MS), myasthenia gravis (MG), myotonic, spinal muscular atrophy (SMA), and other conditions. After a history is taken and a physical examination performed, the evaluating professionals may require further diagnostic modalities in the evaluation of neuromuscular disorders, which may include:

NCSs.

NEMGs.

Autonomic reflex testing.

Cardiovascular autonomic testing.

Muscle and/or nerve biopsies.

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EMG and NCV are the most commonly performed tests; in past decades, both were considered standards. However, both tests require needle insertion, which can be uncomfortable for many patients. In most states, the insertion of needles can only be performed by physicians or other PCPs with licenses that include this scope of practice. Newer technologies use surface methods to assess nerve and muscle performance, which allow for greater patient comfort and the ability of providers not licensed to insert needles, to perform these non-invasive, surface tests. During a surface electromyography (SEMG), in lieu of needles, surface electrodes are placed on the overlying affected muscles. Although the technique is less invasive, SEMGs have a lower signal resolution and are subject to greater muscle movement artifact. While SEMGs may improve amplitude, studies do not demonstrate SEMGs to be superior, or even equal, to the diagnostic capabilities of NEMGs. In 2000, the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) reviewed the efficacy of SEMGs. The following conclusions were drawn (and have not since been updated):

Based on Class II data, SEMG is considered unacceptable as a clinical tool in the diagnosis of neuromuscular disease at this time (Type E recommendation).

Based on Class III data and inconclusive or inadequate Class II data, SEMG is considered unacceptable as a clinical tool in the diagnosis of low back pain at this time (Type E recommendation).

Based on Class III data, SEMG is considered an acceptable tool for kinesiology analysis of movement disorders; for differentiating types of tremors, myoclonus, and dystonia; for evaluating gait and posture disturbances; and for evaluating psychophysical measures of reaction and movement time (Type C recommendation).

Meekins, So, and Quan wrote the review of SEMG for the AANEM in 2008. Their meta-analysis of the literature subsequent to the AAN’s position paper concluded that the technology was of possible assistance in diagnosis of neuromuscular diseases, fatigue associated with post-polio syndrome and electromechanical function in myotonic dystrophy. All of these were a Level C recommendation. There is insufficient data to support the use of SEMG in distinguishing between neuropathic and myopathic conditions, or for the diagnosis of specific neuromuscular diseases. In 2009, the International Chiropractors Association (ICA, California) developed consensus-based guidelines, which indicated the use of SEMG may be helpful in the evaluation of cervical spine pain, trapezius pain and low back disorders in patients with a whiplash injury. This guideline did not provide any strength-of-evidence statements, but represented the opinion of the authors. NCSs, also termed NCV studies, are used in assessing the health of peripheral nerves. These studies measure the patient’s response to electrical stimulation, applied via a surface electrode. Sensory function is measured through another surface electrode, which is placed over the skin in the distribution area of the peripheral nerve being tested. The motor responses are measured by the muscle’s response, as detected by an electrode placed over the muscle with the innervation in question. Nerve conduction studies assess the speed (i.e., conduction velocity or latency), size or amplitude, and shape of the patient’s response to the electrical stimulation. Common Symptoms

Diagnosis

Generalized weakness

Neuropathies.

Myopathies (including endocrine).

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Motor system disease (e.g., ALS).

Neuromuscular junction disorder (e.g., MG).

Facial weakness (including ptosis)

Facial (seventh cranial) nerve lesions.

Myopathy.

Neuromuscular junction disorder (e.g., MG).

Facial pain and/or numbness; involuntary facial movement

Injury of the trigeminal (fifth cranial) nerve.

Myokymia.

Hemifacial spasm.

Dysphagia Dysarthria

Myopathy.

Neuromuscular junction disorder (e.g., MG).

Motor system disease (e.g., ALS).

Respiratory insufficiency

Injury of the hypoglossal (12th cranial) nerve.

Neuromuscular junction disorder (e.g., MG).

Motor system disease (e.g., ALS).

Neck pain

Phrenic nerve lesions.

Myopathy (e.g., acid maltese deficiency).

MG.

Motor system disease (e.g., ALS).

Cervical radiculopathy.

Thoracic pain Back pain

Brachial plexopathy.

Focal neuropathy (e.g., spinal accessory nerve).

Shoulder and arm pain, numbness, altered sensation (e.g., pins and needles), weakness, cramps, fasciculations, muscle atrophy or hypertrophy (focal or diffuse) Hip and leg pain, numbness, altered sensation (i.e., pins and needles), weakness, cramps, fasciculations, muscle atrophy, or hypertrophy

Thoracic radiculopathy.

Lumbosacral radiculopathy.

Lumbosacral plexopathy.

Cervical radiculopathy.

Brachial plexopathy.

Polyneuropathy.

Focal neuropathy (e.g., carpal tunnel syndrome, ulnar nerve injury at the elbow, suprascapular nerve injury at the shoulder).

Myopathy.

Motor system disease (e.g., ALS).

Syrinx.

Urinary and anal sphincter dysfunction

Lumbosacral radiculopathy.

Lumbosacral plexopathy.

Polyneuropathy.

Focal neuropathy (e.g., tarsal tunnel syndrome, femoral [focal or diffuse] mononeuropathy).

Myopathy.

Motor system disease (e.g., ALS).

Distal weakness

Lumbosacral radiculopathy.

Cauda equina syndrome.

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Perineal neuropathy.

Lumbar stenosis.

Polyradiculopathy.

Pudendal nerve injury.

Diffuse lumbosacral root injury.

Proximal weakness Polyneuropathy.

Focal mononeuropathy (e.g., carpal tunnel syndrome, ulnar neuropathy).

Myopathy (e.g., inclusion body myositis, distal myopathy).

Myopathy.

Plexopathy.

From Referral Guidelines for Electrodiagnostic Medicine Consultations Approved by the AAEM: August 1996. www.aanem.org/Practice/Position-statements.aspx. Last accessed November 8, 2015.

Several new technologies entered the market over the past decade. Their goals were to duplicate the results of NEMGs and NCSs and make electro diagnostics easier. However, there are no sufficient studies to demonstrate their equivalency in real world settings. For this reason, tests such as QST for diagnosis of lower extremity peripheral neuropathy, NC-stat System, and NK Pressure-Specified Sensory Device remain the standard electro diagnostics tests. Searches Keystone First searched PubMed and the databases of:

UK National Health Services Centre for Reviews and Dissemination.

Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other evidence-based practice centers.

The Centers for Medicare & Medicaid Services (CMS). We conducted searches on December 7, 2015. Search terms were “nerve conduction study, MeSH” and “Electromyogram, MeSH.” We included:

Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

Guidelines based on systematic reviews.

Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies — which also rank near the top of evidence hierarchies.

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Findings

Electrodiagnostic testing is key to determining the cause of neuropathic and myopathic symptoms. The most widely studied tools are NEMGs and NCSs, used in tandem.

Assessed NEMG activity includes insertional activity, spontaneous activity, and voluntary motor-unit action potential. Through NEMG there can be localization of the disorder, chronicity and determination as to the pathophysiology being neuropathic or myopathic, and/or if it is associated with a neuromuscular junction disorder (Preston, 2002).

Standard NCSs with specifically placed skin electrodes can ascertain amplitude, duration, area, latency, and conduction velocity.

SEMG is a new emerging technology, but recent studies fail to demonstrate its superiority to NEMG. The available studies are at a Level III and do not instill a high level of confidence.

Because of symptoms that may mimic other conditions, NEMGs and NCSs should be paired. Policy updates: None. Summary of clinical evidence:

Citation Content, Methods, Recommendations

Meekins, AANEM (2008) Review of past guidelines and current literature to date of article

Key points:

SEMG measures myoelectric signals recorded from sensors placed on the skin surface, making this a potentially useful technology.

Concluded that SEMG adds no clinical utility over NEMG for diagnosis of neuromuscular disease.

Additional data is at a level C (class III data) for distinguishing between neuropathic and myopathic conditions, or for fatigue associated with post-polio syndrome.

Drost (2006) Review of 29 clinical studies and four reviews of high density-surface EMGs

Key points:

Studies show there has been significant technical advancement in optimizing the HD SEMG techniques.

In principle, HD SEMG allows pathological changes at the muscle unit level to be detected, especially for neurogenic disorders and channelopathies.

The studies did not meet the level of evidence necessary for high-level clinical evidence; therefore, recommendations are for further development and implementation of HD SEMG as a clinical diagnostic tool.

Rubin (2012) Paper is a review of the technical issues with electro diagnostic studies of NCS and EMG

Key points:

Potential technical problems encountered during studies may interfere with accurate and reliable acquisition of information. These are discussed in this paper.

Wilbourn (2002) Review of nerve conduction studies for neurologists

Key points:

Important elements of a NCS include amplitude, duration, area,

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Citation Content, Methods, Recommendations

latency, and conduction velocity.

Nerve lesions cause axon loss or demyelination, which have distinctive NCS patterns.

Role of NCS and NEMGs is to localize nerve lesions as accurately as possible.

Papanas (2011) Neuropathy needs to be diagnosed early to prevent complications such as neuropathic pain

Key points:

New tests are classified into those assessing large-fiber function and small-fiber function.

Emerging tests are promising, but must be evaluated in prospective studies.

Cost-effectiveness needs more careful appraisal.

Clinician should still rely on established modalities to diagnose neuropathy.

Glossary Electrodiagnostic medicine (EDX) — Medical subspecialty that applies neurophysiologic techniques to diagnose, evaluate, and treat patients with impairments of the neurologic, neuromuscular, and/or muscular systems. Electromyogram (EMG) — A diagnostic test that measures the electrical activity of muscles at rest and during contraction. Needle electromyogram (NEMG) — Diagnostic test wherein a needle is inserted into a muscle. Neuromuscular activity is recorded after electrical stimulation. Nerve conduction study (NCS) — Diagnostic test that measures the movement of an impulse through a nerve, after electrical stimulation of the nerve. Surface electromyogram (SEMG) — Noninvasive diagnostic test that records muscle activity after electric stimulation, which is performed at the surface level. References Professional society guidelines/other: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Proper performance and interpretation of electrodiagnostic studies. Muscle Nerve. March 2006; 33(3):436-9. American Association of Electrodiagnostic Medicine. AAEM position statements. Who is qualified to practice electrodiagnostic medicine? Muscle Nerve Suppl. 1999; 8:S263-5. Approved May, 1999, and reconfirmed May 2012 http://aanem.org/Practice/Position-statements.aspx. Last accessed December 8, 2015. International Chiropractors Association of California. Management of whiplash associated disorders. Sacramento (CA): International Chiropractors Association of California; 2009.

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Jablecki CK, Andary MT, Floeter MK, Miller RG, Quartly CA, Vennix MJ, Wilson JR; American Association of Electrodiagnostic Medicine; American Academy of Neurology; American Academy of Physical Medicine and Rehabilitation. Practice parameter: Electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology. June 11, 2002; 58(11):1589-92 Keith MW, Masear V, Chung K, Maupin K, Andary M, Amadio PC, Barth RW, Watters WC 3rd, Goldberg MJ, Haralson RH 3rd, Turkelson CM, Wies JL. Diagnosis of carpal tunnel syndrome. J Am Acad Orthop Surg. June 2009; 17(6):389-96. Meekins GD, So Y, Quan D. American Association of Neuromuscular & Electrodiagnostic Medicine evidenced-based review: use of surface electromyography in the diagnosis and study of neuromuscular disorders. Muscle Nerve. October 2008; 38(4):1219-24. Pullman SL, Goodin DS, Marquinez AI, Tabbal S, Rubin M. Clinical utility of surface EMG: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. July 25, 2000; 55 (2):171-7. Peer-reviewed references (SEMG): Criswell E, Cram's Introduction to Surface Electromyography, Second Edition, Jones and Bartlett Publishers, 40 Tall Pine Drive, Sudbury, Ma.01776 Drost G, Stegeman DF, van Engelen BG, Zwarts MJ. Clinical applications of high-density surface EMG: a systematic review. J Electromyogr Kinesiol. December 2006; 16(6):586-602. Hogrel JY. Clinical applications of surface electromyography in neuromuscular disorders. Neurophysiol Clin. July 2005; 35(2-3):59-71. Lahrmann H, Zifko U, Grisold W. Clinical utility of surface EMG: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. May 22, 2001; 56(10):1421. Preston DC, Shapiro BE. Needle electromyography. Fundamentals, normal and abnormal patterns. Neurol Clin. May 2002; 20(2):361-96, vi. Rubin DI. Technical issues and potential complications of nerve conduction studies and needle electromyography. Neurol Clin. May 2012; 30(2):685-710. Wimalaratna HS, Tooley MA, Churchill E, Preece AW, Morgan HM. Quantitative surface EMG in the diagnosis of neuromuscular disorders. Electromyogr Clin Neurophysiol. April – May 2002; 42(3):167-74. Point of care (NCV) Hayes INC., NK Pressure-Specified Sensory Device™ (Sensory Management Services LLC) for Tarsal Tunnel Syndrome Diagnosis, October 10, 2006.

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Hayes, Nc-stat® System (NeuroMetrix Inc.) for Noninvasive Nerve Conduction Testing of Upper Extremity Neuropathy, February 27, 2007. Hayes, Quantitative Sensory Testing for Diagnosis of Lower Extremity Peripheral Neuropathy, November 25, 2013. Perkins BA, Grewal J, Ng E, Ngo M, Bril V. Validation of a novel point-of-care nerve conduction device for the detection of diabetic sensorimotor polyneuropathy. Diabetes Care. September 2006; 29(9):2023-7. Papanas N, Ziegler D. New diagnostic tests for diabetic distal symmetric polyneuropathy. J Diabetes Complications. January – February 2011; 25(1):44-51. Wilbourn AJ. Nerve conduction studies. Types, components, abnormalities, and value in localization. Neurol Clin. May 2002; 20(2):305-38. Clinical trials: Searched clinicaltrials.gov on December 7, 2015, using terms nerve conduction studies| Open Studies. 50 studies found, three relevant. National Institutes of Health Clinical Center (NIHCC) ( National Institute of Neurological Disorders and Stroke (NINDS) ) Training for Diagnosing Neurological Disorders, NCT 00132353, National Institute of Neurological Disorders and Stroke (NINDS) . ClinicalTrials.gov website. http://clinicaltrials.gov/ct2/show/NCT00132353?term=nerve+conduction+study&rank=16. Published August, 2005 Updated March 2015. Accessed December 7, 2015.

University of Southern California Surface EMG Biofeedback for Children With Cerebral Palsy NCT01681888 University of Southern California . ClinicalTrials.gov website http://clinicaltrials.gov/ct2/show/NCT01681888?term=surface+emg&rank=3. Published July 2012. Updated May 2015. Accessed December 7, 2015.

University of Toledo Health Science Campus Preoperative Prevalence of Ulnar Neuropathy and Changes in Ulnar Nerve Latency During Surgery NCT02533024.ClinicalTrials.gov website https://clinicaltrials.gov/ct2/show/NCT02533024?term=Nerve+conduction+study&recr=Open&no_unk=Y&rank=14. Published August 20, 2015. Updated August 2015. Accessed December 7, 2015. CMS National Coverage Determinations (NCDs): National Coverage Determination (NCD) for Sensory Nerve Conduction Threshold Tests (sNCTs) (160.23) Effective April 1, 2004. http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=270&ncdver=2&DocID=160.23+&bc=gAAAAAgAAAAAAA%3d%3d&. Accessed December 7, 2015. Local Coverage Determinations (LCDs): Local Coverage Determination (LCD): Nerve Conduction Studies and Electromyography (L34594). Revised 10/01/2015, no change to coverage. https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34594&ContrId=143&ver=12&ContrVer=1. Accessed December 7, 2015.

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Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly.

CPT Code Description Comments

95860 Needle electromyography; 1 extremity with or without related paraspinal areas. And subsequent codes related to electromyography.

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 muscles, unilateral

95868 Needle electromyography; cranial nerve supplied muscles, bilateral

95870 Needle electromyography, limited study of muscles in 1 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.

95885 Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited.

Add-on code

95886

Needle electromyography, each extremity, with related paraspinal areas, when 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

Add-on code

95887 Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitutde and latency/velocity study.

Add-on code

95905

Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report.

Frequently used in “point of care” studies

95907 Nerve conduction studies; 1-2 studies.

95908 Nerve conduction studies, 3-4 studies.

95909 Nerve conduction studies, 5-6 studies.

95910 Nerve conduction studies, 7-8 studies.

95911 Nerve conduction studies, 9-10.

95912 Nerve conduction studies, 11-12.

95913 Nerve conduction studies, 13 or more studies.

ICD-10 Code Description Comments

E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy

E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy

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E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy

E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy

E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E30.9 Disorder of puberty, unspecified E34.1 Other hypersecretion of intestinal hormones E34.8 Other specified endocrine disorders E34.9 Endocrine disorder, unspecified E35 Disorders of endocrine glands in diseases classified elsewhere G12.21 Amyotrophic lateral sclerosis G50.0 Trigeminal neuralgia G50.1 Atypical facial pain G50.8 Other disorders of trigeminal nerve G50.9 Disorder of trigeminal nerve, unspecified G51.0 Bell's palsy G51.1 Geniculate ganglionitis G51.2 Melkersson's syndrome G51.3 Clonic hemifacial spasm G51.4 Facial myokymia G51.8 Other disorders of facial nerve

G51.9 Disorder of facial nerve, unspecified

G52.3 Disorders of hypoglossal nerve G54.0 Brachial plexus disorders G54.1 Lumbosacral plexus disorders G54.2 Cervical root disorders, not elsewhere classified G54.3 Thoracic root disorders, not elsewhere classified G54.4 Lumbosacral root disorders, not elsewhere classified G54.5 Neuralgic amyotrophy G54.6 Phantom limb syndrome with pain G54.7 Phantom limb syndrome without pain G54.8 Other nerve root and plexus disorders G54.9 Nerve root and plexus disorder, unspecified G55 Nerve root and plexus compressions in diseases classified elsewhere G56.00 Carpal tunnel syndrome, unspecified upper limb G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, left upper limb

G56.10 Other lesions of median nerve, unspecified upper limb G56.11 Other lesions of median nerve, right upper limb G56.12 Other lesions of median nerve, left upper limb G56.20 Lesion of ulnar nerve, unspecified upper limb G56.21 Lesion of ulnar nerve, right upper limb

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G56.22 Lesion of ulnar nerve, left upper limb G56.30 Lesion of radial nerve, unspecified upper limb G56.31 Lesion of radial nerve, right upper limb G56.32 Lesion of radial nerve, left upper limb G56.40 Causalgia of unspecified upper limb G56.41 Causalgia of right upper limb G56.42 Causalgia of left upper limb G56.80 Other specified mononeuropathies of unspecified upper limb G56.81 Other specified mononeuropathies of right upper limb G56.82 Other specified mononeuropathies of left upper limb G56.90 Unspecified mononeuropathy of unspecified upper limb G56.91 Unspecified mononeuropathy of right upper limb G56.92 Unspecified mononeuropathy of left upper limb G57.30 Lesion of lateral popliteal nerve, unspecified lower limb G57.31 Lesion of lateral popliteal nerve, right lower limb G57.32 Lesion of lateral popliteal nerve, left lower limb G57.40 Lesion of medial popliteal nerve, unspecified lower limb G57.41 Lesion of medial popliteal nerve, right lower limb G57.42 Lesion of medial popliteal nerve, left lower limb G57.50 Tarsal tunnel syndrome, unspecified lower limb G57.51 Tarsal tunnel syndrome, right lower limb

G57.52 Tarsal tunnel syndrome, left lower limb G57.60 Lesion of plantar nerve, unspecified lower limb G57.61 Lesion of plantar nerve, right lower limb G57.62 Lesion of plantar nerve, left lower limb G57.70 Causalgia of unspecified lower limb G57.71 Causalgia of right lower limb G57.72 Causalgia of left lower limb G57.80 Other specified mononeuropathies of unspecified lower limb G57.81 Other specified mononeuropathies of right lower limb G57.82 Other specified mononeuropathies of left lower limb G57.90 Unspecified mononeuropathy of unspecified lower limb G57.91 Unspecified mononeuropathy of right lower limb G57.92 Unspecified mononeuropathy of left lower limb G58.7 Mononeuritis multiplex G58.8 Other specified mononeuropathies G58.9 Mononeuropathy, unspecified

G59 Mononeuropathy in diseases classified elsewhere G60.0 Hereditary motor and sensory neuropathy G60.1 Refsum's disease G60.2 Neuropathy in association with hereditary ataxia G60.3 Idiopathic progressive neuropathy G60.8 Other hereditary and idiopathic neuropathies G61.0 Guillain-Barre syndrome G70.00 Myasthenia gravis without (acute) exacerbation G70.01 Myasthenia gravis with (acute) exacerbation

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G71.0 Muscular dystrophy G71.11 Myotonic muscular dystrophy G71.12 Myotonia congenita G71.13 Myotonic chondrodystrophy G71.14 Drug induced myotonia G71.19 Other specified myotonic disorder G71.2 Congenital myopathies G71.3 Mitochondrial myopathy, not elsewhere classified G71.8 Other primary disorders of muscles G71.9 Primary disorder of muscle, unspecified G72.0 Drug-induced myopathy G72.1 Alcoholic myopathy G72.2 Myopathy due to other toxic agents G72.3 Periodic paralysis G72.41 Inclusion body myositis [IBM] G72.49 Other inflammatory and immune myopathies, not elsewhere classified G72.81 Critical illness myopathy G72.89 Other specified myopathies G72.9 Myopathy, unspecified G73.7 Myopathy in diseases classified elsewhere G83.4 Cauda equina syndrome

G93.3 Postviral fatigue syndrome G95.0 Syringomyelia and syringobulbia M05.40 Rheumatoid myopathy with rheumatoid arthritis of unspecified site M05.411 Rheumatoid myopathy with rheumatoid arthritis of right shoulder M05.412 Rheumatoid myopathy with rheumatoid arthritis of left shoulder M05.419 Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder M05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbow M05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbow M05.429 Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow M05.431 Rheumatoid myopathy with rheumatoid arthritis of right wrist M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist M05.439 Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist M05.441 Rheumatoid myopathy with rheumatoid arthritis of right hand M05.442 Rheumatoid myopathy with rheumatoid arthritis of left hand M05.449 Rheumatoid myopathy with rheumatoid arthritis of unspecified hand M05.451 Rheumatoid myopathy with rheumatoid arthritis of right hip

M05.452 Rheumatoid myopathy with rheumatoid arthritis of left hip M05.459 Rheumatoid myopathy with rheumatoid arthritis of unspecified hip M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee M05.469 Rheumatoid myopathy with rheumatoid arthritis of unspecified knee M05.471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot M05.472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot

M05.479 Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot

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M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites M25.511 Pain in right shoulder M25.512 Pain in left shoulder M25.519 Pain in unspecified shoulder M25.521 Pain in right elbow M25.522 Pain in left elbow M25.529 Pain in unspecified elbow M25.551 Pain in right hip M25.551 Pain in right hip M25.559 Pain in unspecified hip M33.02 Juvenile dermatopolymyositis with myopathy M33.12 Other dermatopolymyositis with myopathy M33.22 Polymyositis with myopathy M33.92 Dermatopolymyositis, unspecified with myopathy M34.82 Systemic sclerosis with myopathy M35.03 Sicca syndrome with myopathy M48.04 Spinal stenosis, thoracic region M48.05 Spinal stenosis, thoracolumbar region M48.06 Spinal stenosis, lumbar region M48.07 Spinal stenosis, lumbosacral region M51.14 Intervertebral disc disorders with radiculopathy, thoracic region

M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region M51.16 Intervertebral disc disorders with radiculopathy, lumbar region M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region M54.11 Radiculopathy, occipito-atlanto-axial region M54.12 Radiculopathy, cervical region M54.13 Radiculopathy, cervicothoracic region M54.14 Radiculopathy, thoracic region M54.15 Radiculopathy, thoracolumbar region M54.16 Radiculopathy, lumbar region M54.17 Radiculopathy, lumbosacral region M54.2 Cervicalgia M54.5 Low back pain M54.6 Pain in thoracic spine M54.89 Other dorsalgia M54.9 Dorsalgia, unspecified M62.50 Muscle wasting and atrophy, not elsewhere classified, unspecified site

M62.511 Muscle wasting and atrophy, not elsewhere classified, right shoulder M62.512 Muscle wasting and atrophy, not elsewhere classified, left shoulder M62.519 Muscle wasting and atrophy, not elsewhere classified, unspecified shoulder M62.521 Muscle wasting and atrophy, not elsewhere classified, right upper arm M62.522 Muscle wasting and atrophy, not elsewhere classified, left upper arm

M62.529 Muscle wasting and atrophy, not elsewhere classified, unspecified upper arm

M62.531 Muscle wasting and atrophy, not elsewhere classified, right forearm M62.532 Muscle wasting and atrophy, not elsewhere classified, left forearm

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M62.539 Muscle wasting and atrophy, not elsewhere classified, unspecified forearm M62.541 Muscle wasting and atrophy, not elsewhere classified, right hand M62.542 Muscle wasting and atrophy, not elsewhere classified, left hand M62.549 Muscle wasting and atrophy, not elsewhere classified, unspecified hand M62.551 Muscle wasting and atrophy, not elsewhere classified, right thigh M62.552 Muscle wasting and atrophy, not elsewhere classified, left thigh M62.559 Muscle wasting and atrophy, not elsewhere classified, unspecified thigh M62.561 Muscle wasting and atrophy, not elsewhere classified, right lower leg M62.562 Muscle wasting and atrophy, not elsewhere classified, left lower leg M62.569 Muscle wasting and atrophy, not elsewhere classified, unspecified lower leg M62.571 Muscle wasting and atrophy, not elsewhere classified, right ankle and foot M62.572 Muscle wasting and atrophy, not elsewhere classified, left ankle and foot

M62.579 Muscle wasting and atrophy, not elsewhere classified, unspecified ankle and foot

M62.58 Muscle wasting and atrophy, not elsewhere classified, other site

M62.59 Muscle wasting and atrophy, not elsewhere classified, multiple sites

M62.81 Muscle weakness (generalized) M62.9 Disorder of muscle, unspecified M63.80 Disorders of muscle in diseases classified elsewhere, unspecified site M63.811 Disorders of muscle in diseases classified elsewhere, right shoulder M63.812 Disorders of muscle in diseases classified elsewhere, left shoulder M63.819 Disorders of muscle in diseases classified elsewhere, unspecified shoulder M63.821 Disorders of muscle in diseases classified elsewhere, right upper arm M63.822 Disorders of muscle in diseases classified elsewhere, left upper arm M63.829 Disorders of muscle in diseases classified elsewhere, unspecified upper arm M63.831 Disorders of muscle in diseases classified elsewhere, right forearm

M63.832 Disorders of muscle in diseases classified elsewhere, left forearm

M63.839 Disorders of muscle in diseases classified elsewhere, unspecified forearm

M63.841 Disorders of muscle in diseases classified elsewhere, right hand

M63.842 Disorders of muscle in diseases classified elsewhere, left hand

M63.849 Disorders of muscle in diseases classified elsewhere, unspecified hand

M63.851 Disorders of muscle in diseases classified elsewhere, right thigh

M63.852 Disorders of muscle in diseases classified elsewhere, left thigh

M63.859 Disorders of muscle in diseases classified elsewhere, unspecified thigh

M63.861 Disorders of muscle in diseases classified elsewhere, right lower leg

M63.862 Disorders of muscle in diseases classified elsewhere, left lower leg

M63.869 Disorders of muscle in diseases classified elsewhere, unspecified lower leg

M63.871 Disorders of muscle in diseases classified elsewhere, right ankle and foot

M63.872 Disorders of muscle in diseases classified elsewhere, left ankle and foot

M63.879 Disorders of muscle in diseases classified elsewhere, unspecified ankle and foot

M63.88 Disorders of muscle in diseases classified elsewhere, other site

M63.89 Disorders of muscle in diseases classified elsewhere, multiple sites

M79.601 Pain in right arm

M79.602 Pain in left arm

M79.603 Pain in arm, unspecified

M79.604 Pain in right leg

M79.605 Pain in left leg

M79.606 Pain in leg, unspecified

M79.609 Pain in unspecified limb

16

M79.621 Pain in right upper arm

M79.622 Pain in left upper arm

M79.629 Pain in unspecified upper arm

M79.631 Pain in right forearm

M79.632 Pain in left forearm

M79.639 Pain in unspecified forearm

M79.641 Pain in right hand

M79.642 Pain in left hand

M79.643 Pain in unspecified hand

M79.644 Pain in right finger(s)

M79.645 Pain in left finger(s)

M79.646 Pain in unspecified finger(s)

M79.651 Pain in right thigh

M79.652 Pain in left thigh

M79.659 Pain in unspecified thigh

M79.661 Pain in right lower leg

M79.662 Pain in left lower leg

M79.669 Pain in unspecified lower leg

M79.671 Pain in right foot

M79.672 Pain in left foot

M79.673 Pain in unspecified foot

M79.674 Pain in right toe(s)

M79.675 Pain in left toe(s)

M79.676 Pain in unspecified toe(s)

M99.22 Subluxation stenosis of neural canal of thoracic region

M99.23 Subluxation stenosis of neural canal of lumbar region

M99.32 Osseous stenosis of neural canal of thoracic region

M99.33 Osseous stenosis of neural canal of lumbar region

M99.42 Connective tissue stenosis of neural canal of thoracic region

M99.43 Connective tissue stenosis of neural canal of lumbar region

M99.52 Intervertebral disc stenosis of neural canal of thoracic region

M99.53 Intervertebral disc stenosis of neural canal of lumbar region

M99.62 Osseous and subluxation stenosis of intervertebral foramina of thoracic region

M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region

M99.72 Connective tissue and disc stenosis of intervertebral foramina of thoracic region

M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region

N31.9 Neuromuscular dysfunction of bladder, unspecified

R06.00 Dyspnea, unspecified

R06.09 Other forms of dyspnea

R06.3 Periodic breathing

R06.83 Snoring

R06.89 Other abnormalities of breathing

R18.8 Other ascites

R20.0 Anesthesia of skin

R20.1 Hypoesthesia of skin

R20.2 Paresthesia of skin

R20.3 Hyperesthesia

R20.8 Other disturbances of skin sensation

R20.9 Unspecified disturbances of skin sensation

R25.0 Abnormal head movements

17

R25.1 Tremor, unspecified

R25.2 Cramp and spasm

R25.2 Cramp and spasm

R25.3 Fasciculation

R25.8 Other abnormal involuntary movements

R25.9 Unspecified abnormal involuntary movements

R29.810 Facial weakness

R47.1 Dysarthria and anarthria

R53.0 Neoplastic (malignant) related fatigue

R53.1 Weakness

R53.81 Other malaise

R53.83 Other fatigue

S04.30XA Injury of trigeminal nerve, unspecified side, initial encounter

S04.31XA Injury of trigeminal nerve, right side, initial encounter

S04.32XA Injury of trigeminal nerve, left side, initial encounter

S04.50XA Injury of facial nerve, unspecified side, initial encounter

S04.51XA Injury of facial nerve, right side, initial encounter

S04.52XA Injury of facial nerve, left side, initial encounter

S04.891A Injury of other cranial nerves, right side, initial encounter

S04.892A Injury of other cranial nerves, left side, initial encounter

S04.899A Injury of other cranial nerves, unspecified side, initial encounter

S14.2XXA Injury of nerve root of cervical spine, initial encounter

S14.3XXA Injury of brachial plexus, initial encounter

S14.9XXA Injury of unspecified nerves of neck, initial encounter

S24.2XXA Injury of nerve root of thoracic spine, initial encounter

S34.21XA Injury of nerve root of lumbar spine, initial encounter

S34.22XA Injury of nerve root of sacral spine, initial encounter

S34.4XXA Injury of lumbosacral plexus, initial encounter

S44.8X1A Injury of other nerves at shoulder and upper arm level, right arm, initial encounter

S44.8X2A Injury of other nerves at shoulder and upper arm level, left arm, initial encounter

S44.8X9A Injury of other nerves at shoulder and upper arm level, unspecified arm, initial encounter

S54.8X1A Unspecified injury of other nerves at forearm level, right arm, initial encounter

S54.8X2A Unspecified injury of other nerves at forearm level, left arm, initial encounter

S54.8X9A Unspecified injury of other nerves at forearm level, unspecified arm, initial encounter

S64.8X1A Injury of other nerves at wrist and hand level of right arm, initial encounter

S64.8X2A Injury of other nerves at wrist and hand level of left arm, initial encounter

S64.8X9A Injury of other nerves at wrist and hand level of unspecified arm, initial encounter

HCPCS Level II Description Comments

G0255 Current perception threshold/sensory nerve conduction test (SNCT), per limb, any nerve [when specified as other portable automated nerve conduction testing]

S3900 Surface electromyography Not covered