nerve conduction velocity studies

7/29/2019 Nerve Conduction Velocity Studies

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Medical Policy Department

Clinical Affairs Division

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract.

Medical technology is constantly changing and we reserves the right to review and update our policies periodically.

Medical Card System, Inc.

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Nerve Conduction Velocity (NCV) & Electromyography (EMG) Studies[Preauthorization Required]

Medical Policy: MP-ME-09-09

Original Effective Date: November 5, 2010

Reviewed: November 5, 2010

Reviewed: November 2, 2011

This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage,

Inc. (Classicare) and Medical Card System, Inc., providers contract, unless specific contract limitations, exclusions or exceptions

apply. Please refer to the members benefit certification language for benefit availability. Managed care guidelines related to referral

authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the

aforementioned exceptions.

DESCRIPTION

Nerve Conduction Velocity Studies (NCV) measures the speed of conduction of impulses through a

nerve. The impulses being measured are artificially supplied by a stimulating electrode placed on the

skin over the nerve. Electrical activity in the nerve being stimulated is measured by recording electrodes

placed on the skin at various distances from the stimulating electrode. The distance between the

stimulating and recording electrodes and the time taken for an electrical impulse to travel between the

electrodes are used to calculate the nerve conduction velocity. Nerve conduction tests have two parts

testing motor and sensory nerve testing.

Nerve conduction velocity studies are performed to evaluate and document a variety of sensory and

motor neuropathological conditions in patients with a suspected diagnosis of nerve dysfunction. Nerve

dysfunction can be manifested in decreased signal amplitude, slowed conduction velocity or increased

latency. Proximal and distal nerve segments may be tested separately to help identify and localize the

cause of the patients condition. Additional tests are sometimes used to evaluate the results of

treatment.

Although the stimulation of nerves is similar with all NCV studies, the characteristics ofmotor, sensory,

and mixed NCS are different.

Motor NCVstudies 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. Responseparameters include amplitude, latency, configuration, and motor conduction velocity.

Sensory NCVstudiesare 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 NCVstudies are performed by applying electrical stimulation near a nerve containing both


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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 NCV studies is referred to as late response (H-reflex and F-wave testing)and is usuallyperformed 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 ofradiculopathies,plexopathies,polyneuropathies, andproximal mononeuropathies. Late

response studiesare additional studies complementary to NCV and are performed during the same

patient evaluation.

Nerve Conduction Velocity Studies (NCV) and Needle electromyography (EMG) are typically performed

together, by trained and qualified practitioners. Both NCV and EMG are used for clinical diagnosis of

peripheral nervous system disorders.

Electromyography (EMG) is the study and recording of Intrinsic Electrical Properties of Skeletal muscles.

This testing is invasive because it requires needle insertion and adjustment at multiple sites, and at

anatomically critical areas.

COVERAGE

Benefits may vary between groups and contracts. Please refer to the appropriate member certificate

and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests,

benefits, and coverage.

INDICATIONS

I. Medical Card System, Inc., (MCS) considers Nerve Conduction Velocity Studies (NCV) medicallynecessary under the following conditions:

Focal neuropathies or compressive lesions such a carpal tunnel syndrome, ulnar neuropathiesor root lesions, for localization

Traumatic nerve lesions, for diagnosis and prognosis Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic,

metabolic or immune

Repetitive nerve stimulation in diagnosis of Neuromuscular Junction disorders such asMyasthenia Gravis, Myasthemic Syndrome

II. MCS considers Electromyography (EMG) medically necessary under the following conditions: Nerve Compression Syndromes, including carpal tunnel syndrome and other focal

compressions

Radiculophaty-Cervical, Lumbosacral Mononeuropathy/Polyneuropathy-Metabolic, degenerative, hereditary


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United States or Puerto Rico, and designated by the American Medical Association

(AMA).

Codes 95860, 95861, 95863, 95864, 95867, 95868, 95869, and 95870 require level 6asupervision, which means the service must be performed personally by the physician

or a Physical therapist who is certified by the American Board of Physical TherapySpecialties (ABPTS) as a qualified electrophysiologic clinical specialist AND is

permitted to provide the service under state law.

Codes 95900, 95903, 95904, 95934, 95936 and 95937 require level 7a supervisionwhich 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

a certification under the general supervision of a physician.

Segmental testingof a single nerve represents a single study. For example, a test of the ulnarnerve at wrist, forearm, below elbow, above elbow, axilla, and supraclavicular regionsrepresents onetest. 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 toestablish 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

Appendix A-Frequency of Testing, and exceptions may result in medical review.

Categorically, there are general standards accepted for repeat electrodiagnostic testing incertain 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.

Note: Sensory Nerve Conduction Threshold Test (sNCT) is not considered medically necessary by MCS.

All uses of sNCT to diagnose sensory neuropathies or radiculopathies are not considered medically

necessary.

MCS considers the following to be experimental and investigational:

Examination/NCV studies using the NC-stat monitor, the Brevio NCS monitor, the Neural-Scan,and other automated devices are considered experimental and investigational.


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NCV studies are considered experimental and investigational for screening for polyneuropathyof diabetes or end-stage renal disease.

CODING INFORMATION

CPT Codesfor Nerve Conduction Velocity Studies (NCS)

CPT Codes DESCRIPTION

95900 Nerve Conduction, amplitude and latency/velocity study. Each nerve; motor, without

F-wade study

95903 Nerve Conduction, amplitude and latency/velocity study, each nerve motor, with F-

wade study

95904 Nerve Conduction, amplitude and latency/velocity study, each nerve; sensory

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

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 one method

*Current Procedural Terminology (CPT) 2011 American Medical Association: Chicago, IL.

CPT Codes for Electromyography (EMG)

CPT Codes DESCRIPTION

95860 Needle electromyography; one extremity with or without related paraspinal areas

95861 Needle electromyography; two extremities with or without related paraspinal areas

95863 Needle electromyography; three extremities with or without related paraspinal areas

95864 Needle electromyography; Four extremities with or without related paraspinal areas

95867 Needle electromyography; Cranial Nerve supplied Muscle(s), Unilateral


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95868 Needle electromyography, Cranial Nerve Supplied Muscles, Bilateral

95869 Needle Electromyography; Thoracic Paraspinal Muscles (Excluding T1 or T2)

95870 Needle Electromyography; Limited study of Muscle in One Extremity or Non-Limb

(Axial) Muscles (Unilateral or Bilateral), other than thoracic Paraspinal, cranial nerve

supplied muscles, or sphinters

95872 Needle electromyography using single fiber electrode, with quantitative

measurement of Jitter, Blocking and/or fiber density, any/all sites of each muscle

studied

*Current Procedural Terminology (CPT) 2011 American Medical Association: Chicago, IL.

ICD-9 CM Diagnosis Codes

ICD-9 CMCODES

DESCRIPTION

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, NOTSTATED 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

337.00 IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY, UNSPECIFIED

337.01 CAROTID SINUS SYNDROME


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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

353.0 BRACHIAL PLEXUS LESIONS

353.1 LUMBOSACRAL PLEXUS LESIONS

353.2 CERVICAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.3 THORACIC ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.4 LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.5 NEURALGIC AMYOTROPHY

354.0 -

354.9

CARPAL TUNNEL SYNDROME - MONONEURITIS OF UPPER LIMB UNSPECIFIED


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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


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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

*2011 ICD-9-CMFor Physicians, VOLUMES I & II, Professional Edition (American Medical Association)

* 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.


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HCPCS CODES NOT COVERED

HCPCS CODES DESCRIPTION

G0255 CURRENT PERCEPTION THRESHOLD/SENSORY NERVE CONDDUCTION TEST,(SNCT) PER

LIMB, ANY NERVE

S3905 NON-INVASIVE ELECTRODIAGNOSTIC TESTING WITH AUTOMATIC COMPUTERIZED

HAND-HELD DEVICE TO STIMULATE AND MEASURE NEUROMUSCULAR SIGNALS

IN DIAGNOSING AND EVALUATING SYSTEMIC AND ENTRAPMENT NEUROPHATHIES*2011 HCPCS LEVEL II Professional Edition (American Medical Association).

REFERENCES

1. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), ProperPerformance and Interpretation of Electrodiagnostic Studies. September 2005.

www.aanem.org/practiceissues/positionstatement/positionstatments.cfm

2. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), RecommendedPolicy for Electrodiagnostic Medicine. Endorsed by the American Academy of Neurology. The

American Academy of Physical Medicine and Rehabilitation and the American Association of

Neuromuscular and Electrodiagnostic Medicine.

www.aanem.org/practiceissues/recPolicy/recommended_policy_1.cfm

3. American Association of Neuromuscular and Electrodiagnostic Medicine (AAEM), Who isqualified to practice electrodiagnostic medicine. Position statement. Approved May 1999.

www.aanem.org/practiceissues/positionstatements/who%27s_Qualified.cfm

4. First Coast Service Options, Inc. LCD for Electromyography and Nerve Conduction Studies(L29325). Determination Effective Date: 1/1/2010. Last review 06/14/2011. Accessed

11/03/2011. No changes for medical Indications. Available athttp://www.cms.gov/medicare-

coverage-database/license/cpt-

license.aspx?from=http*3a%24%2f%2fwww.cms.gov%2fmedicare-coverage-

database%2findexes%2flcd-

list.aspx%3fCntrctr%3d198%26ContrVer%3d1%26CntrctrSelected%3d198*1%26name%3dFirst%

2bCoast%2bService%2bOptions%2c%2bInc.%2b(09202%2c%2bMAC%2b-

%2bPart%2bB)%26s%3d46%26bc%3dAggAAAAAAAAA%26&npage=/medicare-coverage-

database/details/lcd-

details.aspx&LCDId=29325&ContrId=198&ver=8&ContrVer=1&CntrctrSelected=198*1&Cntrctr=

198&name=First+Coast+Service+Options%2c+Inc.+(09202%2c+MAC+-

+Part+B)&s=46&bc=AggAAAIAAAAA&


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5. NCS System. NeuroMetrix. Nerve Conduction on Studies. 2008.6. www.ECRI.org. Point of Care Nerve Conduction Tests. Published: 05/02/2007.

POLICY HISTORY

DATE ACTION COMMENT

November 5, 2009 Origination of Policy

November 5, 2010 Yearly Review Added code 95905

November 2, 2011 Yearly Review

This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of

benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with

the terms of the members plan in effect as of the date services are rendered. Medical Card System, Inc., (MCS) medical policies are

developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but

not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical

practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical

Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion Medical Card System, Inc., (MCS)

medical policies are intended to serve as a resource to the plan. They are not intended to limit the plans ability to interpret plan language as

deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type,

quality, and levels of care and treatment they choose to provide.

APPENDIX A-Frequency of Testing

The following table lists the American Association of Neuromuscular & Electrodiagnostic Medicine's (formerly

known as American Association of Electrodiagnostic Medicine) recommendations concerning a reasonable

maximum number of NCV studies, needle EMG and other EMG studies per diagnostic category needed for a

physician to render a diagnosis. Each number in the Maximum Number of Studies Table represents 1 study or

Unit.

Table : Maximum Number of Studies

Needle

Electromyography, CPT

95860-95864 and

Nerve Conduction

Studies CPT 95900,

Other Electromyographic

Studies CPT 95934, 95936,


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95867-95870 95903, 95904 95937

Indications Number of Services

(Tests)

Motor

NCS with

And/or

without F

wave

Sensory

NCS

H-

Reflex

Neuromuscular

Junction Testing

(Repetitive

Stimulation)

Carpal Tunnel (Unilateral) 1 3 4 - -

Carpal Tunnel (Bilateral) 2 4 6 - -

Radiculopathy 2 3 2 2 -

Mononeurophathy 1 3 3 2 -

Polyneuropathy/Mononeuropathy

Multiplex

3 4 4 2 -

Myopathy 2 2 2 - 2

Motor Neuronopathy (e.g., ALS) 4 4 2 - 2

Plexopathy 2 4 6 2 -

Neuromuscular Junction 2 2 2 3

Tarsal Tunnel Syndrome (Unilateral) 1 4 4 - -

Tarsal Tunnel Syndrome (Bilateral) 2 5 6 - -

Weakness, Fatigue, Cramps, or Twitching

(focal)

2 3 4 - 2

Weakness, Fatigue, Cramps, or Twitching

(General)

4 4 4 2

Pain, Numbness, or Tingling (Unilateral) 1 3 4 2 -

Pain, Numbness, or Tingling (Bilateral) 2 4 6 2 -

nerve conduction velocity studies

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