Electromyography and Nerve Conduction Studies (EMG/NCS) Reimbursement Policy
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Reimbursement and billing guidelines for EMG and NCS performed for Healthfirst members across identified lines of business; applies to providers performing these diagnostic services and outlines documentation, supervision, limitations, and coding requirements.
Qualified provider requirements were revised to require that electrodiagnostic testing be ordered and overseen by a qualified physician, with documentation supporting the physician's review of the findings and resulting diagnosis.
Physician qualification language was revised by removing references to specific specialty training, credentialing standards, and examples of qualified physician specialties.
Added requirements for EMG testing performed by physical therapists, including appropriate certification and qualifications, performance pursuant to a referring physician's order, and compliance with applicable state law.
Medical Necessity, Provider Qualifications, and Limitations
Medical necessity and documentation criteria
Covered when ALL of the following are met:
ALL of the following
- The test is medically necessary for diagnosis, evaluation, or management of peripheral nerve or neuromuscular disorders (e.g., peripheral neuropathy, radiculopathy, nerve entrapments, neuromuscular junction disorders) or provides guidance for procedures.
- The test is performed by qualified healthcare professionals with appropriate training and clinical expertise.
- Documentation supports clinical indication, procedures performed, response parameters obtained, provider qualifications, interpretation of results, and type of equipment used.
- Requests for testing are subject to review by Healthfirst Utilization Management using the criteria in MP-093; final reimbursement is subject to member benefits and provider contract.
Provider qualifications and supervision
Provider performance and supervision requirements depend on line of business and applicable state law; ALL applicable items below must be satisfied.
ALL of the following
Medicare lines of business (MA HMO, MA PPO, CompleteCare, IB-Dual):
- Healthfirst follows applicable CMS guidelines including LCD L35098 for EMG/NCS; supervision and performance must align with those CMS rules.
Other Lines of Business (CHP, MMC, EP, HARP, QHP):
- Testing should be ordered and overseen by a qualified physician with expertise in neurological conditions (e.g., neurologist, physiatrist) or a physician meeting equivalent training/credentialing standards.
- Physical Therapists (PT) may perform specified procedures only if they hold ABPTS certification and any additional procedural certification required, and only as permitted by state law and the supervision indicators assigned to the CPT code.
- When PTs perform testing under supervision level descriptors: certified PTs may fully perform TC & PC where allowed (e.g., supervision level 7A/77 for certain NCS codes); non-certified PTs may perform the technical component (TC) only under direct physician supervision, with the PC performed by a physician as required by supervision level definitions.
- Certain codes carry specific supervision restrictions (e.g., CPT 95905 is not reimbursable when performed by PTs because it lacks permissible PT supervision indicators).
Limitations & exclusions
The following scenarios are NOT covered or are limited:
Non-covered or excluded scenarios
- Routine screening for diabetic or ESRD-related neuropathy without specific clinical indications is not covered.
- NCS that do not provide real-time response parameters (amplitude, latency, conduction velocity) will not be reimbursed.
- Data transmitted electronically or over the internet without real-time response data, or tests performed with portable or automated devices that assess only limited parameters, are not considered medically necessary.
- NCS performed with fixed templates or computer-generated reports as routine adjuncts are not acceptable.
- Repetitive stimulation testing for diabetic neuropathy or routine carpal/tarsal tunnel syndrome screening is not covered unless there is clinical suspicion of a neuromuscular disorder.
- EMG of only intrinsic foot muscles or testing in regions with surgical scars without other supporting findings is not covered.
- EMG performed shortly after trauma before abnormalities are expected to be detectable is not covered.
- Surface or macro-EMG studies, multiple EMG studies at the same site solely to optimize botulinum toxin injections, and SEPs/SERs performed outside approved indications are not covered.
EMG/NCS Codes and Technical Requirements
| 95860 | Needle electromyography; 1 extremity with or without related paraspinal areas. |
| 95861 | Needle electromyography; 2 extremities with or without related paraspinal areas. |
| 95863 | Needle electromyography; 3 extremities with or without related paraspinal areas. |
| 95864 | Needle electromyography; 4 extremities with or without related paraspinal areas. |
| 95867 | Needle electromyography; cranial nerve supplied muscle(s), unilateral. |
| 95868 | Needle electromyography; cranial nerve supplied muscle(s), bilateral. |
| 95869 | Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12). |
| 95870 | Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve. |
| 95885 | Needle Electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (list separately in addition to code for primary). |
| 95886 | Needle Electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscle studied, innervated by three or more nerves or four or more spinal LE. |
| 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 studies. |
| 95912 | Nerve conduction studies; 11-12 studies. |
| 95913 | Nerve conduction studies (listed in source as part of series 95907-95913). |
| 95937 | Neuromuscular Junction Testing (TC/PC supervision noted) |
Prior Authorization and Claim Adjudication
Prior authorization and claim adjudication: UM review per MP-093
Requests for EMG/NCS testing will be reviewed by Healthfirst's Utilization Management (UM) team using the criteria in MP-093; final reimbursement is determined by benefit coverage and the provider's contract, and claims not adhering to this policy will be denied or rejected.
- Reimbursement determined by provider contract and benefit coverage per MP-093.
- Providers are responsible for accurate coding; non-adherent claims will be denied or rejected.
- Final reimbursement depends on medical necessity, state/federal mandates, and timely filing rules in the provider contract.
Key Terms
Material Changes and Policy Updates
Revised qualified provider requirements to require electrodiagnostic testing be ordered and overseen by a qualified physician with documentation of the physician's review and diagnosis; physician qualification language was broadened by removing references to specific specialty training and credentialing examples.
Policy effective date established for the revised EMG/NCS reimbursement and documentation requirements.
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