Nerve Conduction Studies and Electromyography

Title XVIII of the Social Security Act, §1861(r)(1) defines the term physician.

Title XVIII of the Social Security Act, §1861(s)(2)(A) defines medical and other health services and (K) addresses services which would be physicians' services if furnished by a physician and which are performed by a physician assistant, nurse practitioner or clinical nurse specialist.

Title XVIII of the Social Security Act, §1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member and (a)(14) defines other than physician services.

42 CFR §410.32(a) indicates that diagnostic tests must be ordered by the treating physician, or other treating practitioner acting within the scope of his or her license and Medicare requirements, who uses the results in the management of the beneficiary's specific medical problem and (b)(3)(i-iii) defines supervision and the three levels of supervision.

42 CFR §410.74 defines physician assistants' services, §410.75 defines nurse practitioners' services and §410.76 defines clinical nurse specialists' services.

42 CFR §419.22 defines hospital services excluded from payment under the hospital outpatient prospective payment system.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.

This A/B MAC expects that all healthcare professionals involved in the performance of electrodiagnostic (ED) testing, including technicians, will be appropriately trained and/or credentialed, either by a formal residency/fellowship program (physicians), certification by a nationally recognized organization, or by an accredited post-graduate training course covering anatomy, neurophysiology and forms of EDs, such as nerve conduction studies (NCS) and electromyography (EMG) that are acceptable to this contractor, in order to provide the proper testing and assessment of the patient's condition, and appropriate safety measures. It would be highly unlikely that this training and/or credentialing is possessed by providers other than neurologists, or physical medicine and rehabilitation physicians.

This A/B MAC also expects that the laboratories in which these studies are performed meet basic safety and quality standards regarding such issues as electrical safety and electrical equipment maintenance, needle handling, blood spill management, etc. Such standards have been established by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM).

The ED evaluation is an extension of the neurologic portion of the history and physical examination. Both require a detailed knowledge of a patient and his/her disease. Training in the performance of ED procedures in isolation of knowledge about clinical diagnostic and management aspects of neuromuscular diseases may not be adequate for proper performance of an ED evaluation and correct interpretation of ED test results. Without awareness of the patterns of abnormality expected in different diseases and knowledge that the results of NCS and EMG may be similar in different diseases, diagnosis solely by EMG-NCS findings may be both inadequate and ultimately be detrimental to the patient.

Guidelines about proper qualifications for qualified health care professionals performing ED evaluations have been developed and published by AANEM and other medical organizations, including the American Medical Association (AMA), the American Academy of Neurology (AAN), the American Academy of Physical Medicine and Rehabilitation (AAPMR), American Neurological Association (ANA), the American Board of Physical Therapy Specialties (ABPTS) in Clinical Electrophysiology, and the Department of Veterans Affairs (VA).

Both EMGs and NCSs are usually required for a clinical diagnosis of peripheral nervous system disorders. Performance of 1 type of testing does not eliminate the need for the other. The intensity and extent of testing with EMG and NCS are matters of clinical judgment developed after the initial pre-test evaluation, and later modified during the testing procedure. This A/B MAC expects that EMGs will be conducted in conjunction with nerve conduction velocity (NCV) in all testing instances. The only exception would be in situations where a contraindication to performing an EMG exists. In such cases, the circumstances for the contraindication should be clearly documented in the medical record.

It is expected that only an appropriate and sufficient number of ED studies will be performed to arrive at an appropriate diagnosis. The AANEM has published a “Model Policy for Needle EMG and NCS” outlining recommendations pertaining to a reasonable maximum number of studies, per diagnostic indication, necessary for a practitioner to arrive at a diagnosis in 90% of patients with that final diagnosis. It is recommended that the ED provider utilize this table as a guideline when performing testing.

Decisions to continue, modify or conclude an EMG/NCS test rely on knowledge of anatomy, physiology and neuromuscular diseases. Ongoing real-time assessment of data is required during the clinical diagnostic evaluation and especially during EMG examination. As such, the provider performing the testing and/or interpretation should be present on the site and immediately available during the examination.

NCS are used to measure action potentials resulting from peripheral nerve stimulation which are recordable over the nerve or from an innervated muscle. With this technique, responses are measured between 2 sites of stimulation, or between a stimulus and a recording site.

NCS are of 2 general types: sensory and motor. Either surface or needle electrodes can be used to stimulate the nerve or record the response. Axonal damage or dysfunction generally results in loss of nerve or muscle potential response amplitude; whereas, demyelination leads to prolongation of conduction time and slowing of conduction velocity.

Obtaining and interpreting NCS results requires extensive interaction between the performing qualified health care professional and patient, and is most effective when both obtaining raw data and interpretation are performed concurrently on a real-time basis.

Results of the NCS reflect on the integrity and function of:

         (I) the myelin sheath (Schwann cell derived insulation covering an axon), and

         (II) the axon (an extension of neuronal cell body) of a nerve.

Interruption of axon and dysfunction of myelin will both affect NCS results.

It is often also valuable to test conduction status in proximal segments of peripheral nerves. This assessment can be accomplished by H-reflex, F-wave and blink reflex testing. These proximal segments include the first several centimeters of a compound nerve emerging from the spinal cord or brainstem. H-reflex, F-waves and blink reflex testing accomplish this task better than distal NCS.

EMG is the study and recording of intrinsic electrical properties of skeletal muscles. This is carried out with a needle electrode. Generally, the needles are of 2 types: monopolar or concentric. EMG is undertaken together 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 times anatomically critical sites. As in NCS, during EMG studies the electromyographer depends on ongoing real-time interpretation based knowledge of the clinical diagnosis being evaluated to decide whether to continue, modify, or conclude a test. This process requires knowledge of anatomy, physiology, and neuromuscular diseases.

EMG results reflect not only on the integrity of the functioning connection between a nerve and its innervated muscle but also on the integrity of a muscle itself. The axon innervating a muscle is primarily responsible for the muscle’s volitional contraction, survival, and trophic functions. Thus, interruption of the axon will alter the EMG. A few prime examples of conditions in which EMG is potentially helpful are disc disease producing spinal nerve dysfunction, advanced nerve compression in peripheral lesions, amyotrophic lateral sclerosis (ALS), polyneuropathy, etc. After an acute neurogenic lesion, EMG changes may not appear for several days to weeks in the innervated muscles. Primary muscle disease such as polymyositis will also alter a normal EMG pattern. Myotonic disorders may show a pattern of spontaneous repetitive discharges on needle exploration.

In summary, axonal and muscle involvement are most sensitively detected by EMGs, and myelin and axonal involvement are best detected by NCSs.

A. Nerve Conduction Studies
The dichotomy into axonal and demyelinating neuropathies provides a practical means of correlating electrical abnormalities with major pathophysiologic changes in the nerve. Electrical studies can be of help in localization of an abnormality, and in distinguishing 1 variety of neuropathy from another: for example, diffuse vs. multifocal; axonal vs. demyelinating. Such distinction has diagnostic value. Specific classification of nerve injuries into neuropraxia and axonotmesis can be made on the basis of conduction studies and EMG. Such classification has a bearing on prognosis and treatment.

1. Focal neuropathies or compressive lesions such as carpal tunnel syndrome, ulnar neuropathies or root lesions, for localization.
2. Traumatic nerve lesions, for diagnosis and prognosis.
3. Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic, metabolic or immune.
4. Repetitive nerve stimulation in the diagnosis of neuromuscular junction disorders such as myasthenia gravis, myasthenic syndrome.
5. There may be other instances, not detailed here, where NCS may be of use. Not all possible or potential indications are addressed here.

The broad diagnostic scope of NCS is recognizable by the foregoing description. There may be instances where questions about an indication, or need for a study, will arise. The clinical history and examination, carried out before the study, must always describe and document clearly and comprehensibly the need for the planned test. A "rule-out" diagnosis is typically not acceptable. The contractor is cognizant of the fact that patients are not always referred with a definite diagnosis in mind. Often, pain, paresthesia, or weakness in an extremity is the reason for a NCS or EMG. These common symptoms result not only from axonal and myelin dysfunction but also from systemic, non-neurological illnesses. EMG and NCV may help in making this distinction. Therefore, symptom-based diagnoses such as "pain in limb" weakness, disturbance in skin sensation or "paresthesia" are acceptable provided the clinical assessment unequivocally supports the need for a study. To cite but 1 example of many, an EMG or NCS is irrelevant as a first order diagnostic test for limb pain resulting from immediate antecedent trauma or acute bone injury.

Both EMGs and NCSs are required for a clinical diagnosis of peripheral nervous system disorders. EMG results reflect on the integrity of the functioning connection between a nerve and its innervated muscle and also on the integrity of a muscle itself. Performance of 1 does not eliminate the need for the other. The intensity and extent of testing with EMG and NCS are matters of clinical judgment developed after the initial pre-test evaluation, and later modified during the testing procedure.

Decisions to continue, modify or conclude a test also rely on a knowledge base of anatomy, physiology and neuromuscular diseases. There is a requirement for ongoing real-time clinical diagnostic evaluation, especially during EMG examination. Also, EMG examination is invasive. Needle placement in the exact muscle of interest is essential. It requires needle exploration near vital structures such as the pleura, femoral neurovascular bundle, peritoneum, intraspinal spaces, carotid artery, orbit and brachial plexus. Risk of infection from acquired immune deficiency syndrome (AIDS), Hepatitis B-E, Creutzfeldt-Jakob encephalopathy, and hemorrhage from anticoagulation can be managed by proper techniques.

The ED evaluation is actually an extension of the neurologic portion of the physical examination. Both require a detailed knowledge of a patient and his/her disease. Training in the performance of ED procedures, in isolation without awareness and ability to diagnose and manage neuromuscular diseases, is not always adequate for ED consultation. Recognition and experience in the management of disparate diseases that produce common ED findings may be necessary. For example, EMG-NCS findings may overlap in the following pairs of disorders: inflammatory myopathies and ALS, ALS and multi-level radiculopathies, myotonia of channelopathies (periodic paralyses) and myotonic dystrophies, focal neuropathies such as carpal tunnel syndrome and proximal plexopathies. Other instances where knowledge of disease behavior is crucial are chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy. These entities display ED features that resemble generalized polyneuropathies. Neuromuscular transmission disorders require separation based on clinical presentation and electrical features. Treatment will depend on differentiating among them. Without awareness of the disease spectrum, diagnosis solely by EMG-NCS findings may be either wrong or detrimental to the patient.

The following definitions are from the AANEM Recommended Policy for Electrodiagnostic Medicine.

The stimulation of nerves is similar across all NCSs; the characteristics of motor, sensory, and mixed NCSs are different and are discussed separately below. In each case, an appropriate nerve is stimulated and recording is made either from the appropriate nerves or from muscle supplied by the motor nerve.

a. Motor -

Motor NCSs 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.

b. Sensory -

Sensory NCSs 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, and configuration and sensory conduction velocity. 

c. Mixed -

Mixed NCSs 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. 

NCS performed independent of needle EMG may only provide a portion of the information needed to diagnose muscle, nerve root, and most nerve disorders. When the NCS is used on its own without integrating needle EMG findings or when an individual relies solely on a review of NCS data, the results can be misleading, and important diagnoses may be missed.

In most instances, both NCS and usually EMG are necessary to perform diagnostic testing. While a provider may choose to perform just a NCS, when performed alone it is usually considered to be a screening exam. The only exception to this is a situation when a provider may consider it appropriate to perform a NCS without doing an EMG for the diagnosis of carpal tunnel syndrome with a high pre-test probability.

B. Electromyography
Neurogenic disorders can be distinguishable from myopathic disorders by a carefully performed EMG. For example, both polymyositis and ALS produce manifest weakness. The former carries a very different prognosis and treatment than the latter. An EMG is very valuable in making this distinction. Similarly, classification of nerve trauma into axonal vs. demyelinating categories, with corresponding differences in prognoses, are possible with EMG. Below is a list of common disorders where an EMG, in tandem with a properly conducted NCS, will be helpful in diagnosis:

1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions.
2. Radiculopathy - cervical, lumbosacral.
3. Mono/polyneuropathy - metabolic, degenerative, hereditary.
4. Myopathy - including poly- and dermatomyositis, myotonic and congenital myopathies.
5. Plexopathy - idiopathic, trauma, infiltration.
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here.
7. At times, immediately prior to botulinum toxin injection, for localization.
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or chemodenervation.

There may be other instances, not detailed here, where EMG may be of use.

Use of EMG with Botulinum Toxin Injection
EMG may be used to optimize the anatomic location of botulinum toxin injection. It is expected there will be 1 study performed per anatomic location of injection, if needed.

Limitations:

Screening testing for polyneuropathy of diabetes or endstage renal disease (ESRD) is NOT covered. Testing for the sole purpose of monitoring disease intensity or treatment efficacy in these 2 conditions is also not covered. 

Current Perception Threshold/Sensory Nerve Conduction Threshold Test (sNCT) – is not covered by Medicare. 

Electromyography
The necessity and reasonableness of the following uses of EMG studies have not been established:

• Exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions
• Definitive diagnostic conclusions based on paraspinal EMG in regions bearing scars of past surgeries (e.g., previous laminectomies)
• Pattern-setting limited limb muscle examinations, without paraspinal muscle testing for a diagnosis of radiculopathy
• EMG testing shortly after trauma, before EMG abnormalities would have reasonably had time to develop
• Surface and macro EMGs
• Multiple uses of EMG in the same patient at the same location of the same limb for the purpose of optimizing botulinum toxin injections.

For outpatient settings other than Comprehensive Outpatient Rehabilitation Facility (CORF), references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act and 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22.) Each practitioner must provide only those services within the scope of practice for each state.

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Documentation Requirements

The patient's medical records must clearly document the medical necessity for the test, including a brief history and exam that ensures the individual(s) that perform/interpret the study do so with adequate knowledge of essential presenting criteria. Data gathered during NCS, however, should be available which reflect the numerical values (latency, amplitude, and nerve conduction), and testing conditions (skin temperature, type of needle, etc.), preferably in a tabular (not narrative) format. The reason for referral and a clear diagnostic impression are required for each study. In cases where a review becomes necessary, a hard copy of waveforms and a complete written report with an interpretation of the test must be submitted upon request. All studies must contain the printed name, signature, and professional designation of ALL individuals, performing, interpreting, and/or supervising the test.

Normal findings and abnormalities uncovered during the study should be documented with the muscles tested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials and interpretation.

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2. AANEM. AANEM position statement: Recommended policy for electrodiagnostic medicine. Updated 2014.
3. Brown E. An evidence based technology assessment of the NC-stat^® device. Published 8/21/08.  
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9. Kong X, Gozani SN, Hayes MT, Weinberg DH. NC-stat sensory nerve conduction studies in the median and ulnar nerves of symptomatic patients. Clin Neurophysiol. 2006;117(2):405-413.
10. Leffler CT, Gozani SN, Cros D. Median neuropathy at the wrist: Diagnostic utility of clinical findings and an automated electrodiagnostic device. J Occup Environ Med. 2000;42(4):398-409.
11. 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. 2006;29(9):2023-2027.
12. Vinik AI, Emley MS, Megerian JT, Gozani SN. Median and ulnar nerve conduction measurements in patients with symptoms of diabetic peripheral neuropathy using the NC-stat^® system. Diabetes Technol Ther. 2004;6(6):816-824.

• EMG
• NCS