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Medical Policy Bulletin
| Title: | Nerve Conduction Studies (NCS) |
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The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
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 Intent |
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The intent of this policy is to communicate the medical necessity criteria for nerve conduction studies (NCS).
Refer to the Cross References Table in this policy for information on the following topics:
- Electromyelogram (EMG) of the anal and urethral sphincter
- EMG performed with biofeedback therapy
- Intraoperative neurophysiological monitoring
- Needle EMG
- Surface EMG
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| Description: |
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NERVE CONDUCTION STUDIES (NCS)
NCS can be used to evaluate both motor and sensory nerve function. NCS aid in the diagnosis of peripheral nerve injuries (eg, carpal tunnel syndrome, sciatica) and diseases that affect the peripheral nervous system (eg, hereditary progressive muscular dystrophy, myasthenia gravis). During NCS, a nerve is stimulated electrically to assess the speed (conduction velocity and/or latency), size (amplitude), and shape of the response. Usually, surface electrodes are used for both stimulating and recording, although needle electrodes may be required in special cases.
Motor NCS 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. Sensory NCS are performed by applying electrical stimulation near a sensory nerve and recording the response from a distant site along the nerve. Mixed NCS are performed by applying electrical stimulation near a nerve that contains both motor and sensory fibers and recording the response from a different location along that same nerve.
SHORT-LATENCY EVOKED POTENTIALS (SEPs)
While motor and sensory NCS generally detect function in large-caliber peripheral nerve fibers, SEPs test conduction in central sensory pathways. SEPs are an extension of the electrodiagnostic evaluation. SEPs are noninvasive studies performed by repetitive submaximal stimulation of a sensory or mixed sensorimotor peripheral nerve. Amplitude, peak, and interpeak latency measurements with side-to-side comparisons are used to assess conduction abnormalities. SEPs have proven useful in evaluating various conditions including, but not limited to, spinal cord trauma, subacute combined degeneration, nontraumatic spinal cord lesions, and multiple sclerosis.
The results of NCS reflect the integrity and function of both the axon of a nerve and the myelin sheath that covers it. Axonal damage or dysfunction generally results in loss of potential amplitude of the nerve or muscle; demyelination leads to a prolonged conduction time. NCS reports should document the nerves that were evaluated, the distance between the stimulation and recording sites, the conduction velocity, the latency values, and the amplitude, all of which help establish the final diagnosis.
Late responses, such as H-reflex and F-wave studies, are performed to evaluate nerve conduction in portions of the nerve that are more proximal to, or near, the spine. Due to their locations, these nerves are inaccessible to direct assessment using conventional techniques. Late responses are often complementary to motor and sensory NCS and are performed during the same evaluation. Electrical stimulation is applied on the skin surface near a nerve site in a manner that sends impulses both proximally and distally. Characteristics of the response, including latency, are assessed. Late responses provide information in the evaluation of radiculopathies, plexopathies, polyneuropathies, and proximal mononeuropathies. Although H-reflex studies are usually performed on the gastrocnemius/soleus muscle complex in the calf, other areas can also be assessed. Abnormalities on H-reflex studies usually indicate spinal stenosis or spinal radiculopathies. F-wave studies are used to obtain a larger number of responses in the motor nerves that are examined. In some instances, it may be appropriate for an individual to perform some motor NCS with F-wave studies and some without. At times, late responses may be the only studies with abnormal results.
Neuromuscular junction studies involve the recording of a muscle response to a series of nerve stimuli before, and at variable intervals after, exercise or transmission of high-frequency stimuli. These tests are used in association with motor and sensory NCS of the same nerves.
QUANTITATIVE SENSORY TESTING (QST)
QST is the noninvasive assessment and quantification of sensory nerve function. QST involves psychophysical tests that are performed to provide a quantitative value to the subjective feeling of sensation. A transcutaneous electrical stimulus is used to determine the minimum stimulus that evokes sensation in the individual. Individuals are asked to identify the absence or presence of stimulus by undergoing a forced-choice protocol, with the threshold of perception as the measured response. Proponents of this test claim that neuropathies can be diagnosed by using transcutaneous electrical stimulus. Stimuli used in QST include touch, pressure, pain, temperature, and vibration. Four methods of QST include:
- Sensory Nerve Conduction Threshold (sNCT) Testing
- Current Perception Threshold Testing (Pain Perception Threshold [PPT] and Pain Tolerance Threshold [PTT])
- Voltage-actuated Sensory Nerve Conduction Threshold (VsNCT)
- Pressure-Specified Sensory Testing
There is a paucity of literature to establish and support the safety and efficacy of QST. Follow-up studies are needed.
Competency to perform NCS can be demonstrated through the completion of specialized training. For physicians, training incorporated into an accredited physician specialty residency program or a post-residency course of study may be used to demonstrate competency. For non-physician practitioners, certification from a clinical specialization program (as provided by the American Board of Physical Therapy Specialties) may demonstrate competency. Regardless of the performing provider, only properly trained physicians should interpret the NCS results. |
| Policy |
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Nerve conduction studies (NCS) are considered medically necessary and, therefore, covered for the following:
- Localization of focal neuropathies or compressive lesions, such as carpal tunnel syndrome, ulnar neuropathies, or root lesions
- Diagnosis and prognosis of traumatic nerve lesions
- Diagnosis or confirmation of suspected generalized neuropathies (eg, diabetic, uremic, metabolic, or immunologic)
- Repetitive nerve stimulation to assist in the diagnosis of neuromuscular junction disorders (eg, myasthenia gravis, myasthenic syndrome)
- Differential diagnosis of symptom-based complaints (eg, pain, weakness, disturbance in skin sensation [eg, burning or tingling]) related to peripheral nerve injuries or diseases that affect the peripheral nervous system
Motor NCS (with and without an F-wave study) and sensory NCS at a frequency of two sessions per calendar year are considered medically necessary and, therefore, covered for most conditions requiring such testing. Please refer to Attachment B of this policy for more detailed information on the recommendations regarding the maximum number of studies that are appropriate for certain conditions and examples of clinical situations where additional testing is considered medically necessary.
In individuals with carpal tunnel syndrome, motor NCS with an F-wave study are considered not medically necessary and, therefore, not covered.
Quantitative sensory testing (QST) for diagnosing and/or managing a disease is considered experimental/investigational and, therefore, not covered because the safety and/or efficacy of QST cannot be established by a review of the available published literature.
Eligible healthcare professional providers performing NCS must be properly trained, licensed, and acting within their state board-defined scope of practice. Documentation of the performing provider's qualifications must be made available to Company upon request.
- Only physicians are eligible to receive reimbursement for the professional component of NCSs. Physicians may also receive reimbursement for the technical component if they performed that service.
- Non-physician professional providers are only eligible to receive reimbursement for the technical component of NCSs
CODING REQUIREMENTS FOR REPORTING NCS
CPT CODES 95900-95904
- 95900, 95903, and/or 95904 should be reported only once per nerve tested when different stimulation sites along the nerves are tested (inching).
- Motor (95900 or 95903), sensory (95904), and mixed sensory (95904) studies on an individual nerve may be billed separately when the nerve has a contralateral counterpart that needs to be studied for comparison purposes.
CPT CODES 95900 AND 95903
- 95900 and 95903 can be billed together for a given individual on the same day of service when multiple nerves are tested (some with and some without F-wave studies) because they describe two distinct and independent services that are provided on the same day.
- 95900 and 95903 cannot be billed together for a given individual for the same day of service for the same nerve.
CPT CODES 95925, 95926, AND 95927 (SEPs)
- 95925 is reported when testing the upper limbs.
- 95926 is reported when testing the lower limbs.
- 95927 is reported when testing the trunk or the head.
CPT CODES 95934 AND 95936
- 95934 and 95936 are defined as unilateral H-reflex study codes and are intended to be reported per study. Two H-reflex studies are generally appropriate in a given examination.
- H-reflex studies are typically performed bilaterally because symmetry of responses is an important criterion to determine abnormality. When a bilateral H-reflex study is performed, the entire procedure must be duplicated for both locations.
CPT CODE 95903
- F-wave studies are billed in combination with the motor nerves that are examined (95903). Although the setup for an F-wave study is similar to the setup for motor NCS, the testing is performed separately from motor NCS and utilizes different machine settings and separate stimulation in order to obtain a larger number of responses (at least ten).
- The number of F-wave studies that need to be performed on an individual depends on the working diagnosis and the electrodiagnostic testing findings already in evidence. It may be appropriate to perform some motor NCS with and some without F-wave studies in the same individual.
Neuromuscular junction testing is generally appropriate for two repetitive stimulations per date of service. |
| Guidelines |
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MEDICARE
This policy is consistent with Medicare's coverage determination.
MINIMUM STANDARDS FOR NERVE CONDUCTION STUDIES (NCS)
The Company has adopted the minimum standards for NCS as defined by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Minimum standards include the following:
- NCS should be medically indicated.
- Testing should be performed using equipment that assesses all parameters of the recorded signals.
- Studies that are performed with devices designed only for screening rather than diagnosing are not eligible for coverage under this policy.
- The number of nerves tested should be the minimum necessary to address the clinical issue; this may include evaluation of one or more nerves that have normal test results for comparative purposes.
- In order to reach an accurate diagnosis, it may be necessary to perform nerve conduction studies (NCS) and EMGs.
Please refer to Attachment B of this policy for the AANEM recommendations regarding the maximum number of studies that should be performed for each condition and examples of clinical situations where additional testing may be appropriate. These recommendations should not apply if the individual requires evaluation by more than one consultant (ie, a second opinion or an expert opinion at a tertiary care center) in a given year or if the individual requires evaluation for a second diagnosis in a given year.
Evaluation with NCS is tailored to the individual; therefore, it is inappropriate to identify set numbers of acceptable studies for a given diagnosis.
In order to reach an accurate diagnosis, it may be necessary to perform both NCS and electromyography (EMG).
US FOOD AND DRUG ADMINISTRATION (FDA) STATUS
The US Food and Drug Administration (FDA) has approved several devices, such as the NC-stat® (NeuroMetrix, Inc.; Waltham, MA) and Brevio® NCS-Monitor (NeuMed, Inc.; West Trenton, NJ) for measuring nerve conduction time. These devices typically function by applying a stimulus to an individual's peripheral nerve.
BENEFIT APPLICATION
Subject to the terms and conditions of the applicable benefit contract, NCS are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.
Examinations that use portable hand-held devices are included in the visit and are not eligible for separate reimbursement. |
| References |
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| Coding Table |
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Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.
In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company. |
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| Code System | Code Number(s) and Narrative(s) |
| CPT | TO REPORT NERVE CONDUCTION STUDIES (NCS), USE THE FOLLOWING CODES
95900; 95903; 95904
TO REPORT SEPS, USE THE FOLLOWING CODES
95925; 95926; 95927
TO REPORT H-REFLEX STUDIES, USE THE FOLLOWING CODES
95934; 95936; 95937
THE FOLLOWING CODES ARE CONSIDERED EXPERIMENTAL/INVESTIGATIONAL FOR QUANTITATIVE SENSORY TESTING (QTS)
0106T; 0107T; 0108T; 0109T; 0110T |
| ICD Procedure | |
| ICD Diagnosis | See Attachment A |
| HCPCS Level II | THE FOLLOWING CODE IS CONSIDERED EXPERIMENTAL/INVESTIGATIONAL FOR NCS
G0255: Current perception threshold/sensory nerve conduction threshold (sNCT) test, per limb, any nerve |
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| Revenue Codes | N/A |
| Cross References |
| Associated attachments to Policy 07.03.18d: Nerve Conduction Studies (NCS) |
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| Cross Reference Policies |
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| Version Effective Date: 10/01/2009 | |
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The Policy Bulletins on this web site were developed to assist AmeriHealth and its subsidiaries ("AmeriHealth") in administering the provisions of the respective benefit programs, and do not constitute a contract. If you are an AmeriHealth member, please refer to your specific benefit program for the terms, conditions, limitations and exclusions of your coverage. AmeriHealth does not provide health care services, medical advice or treatment, or guarantee the outcome or results of any medical services/treatments. The facility and professional providers are responsible for providing medical advice and treatment. Facility and professional providers are independent contractors and are not employees or agents of AmeriHealth. If you have a specific medical condition, please consult with your doctor. AmeriHealth reserves the right at any time to change or update its Policy Bulletins. ©2010 AmeriHealth, Inc. All Rights Reserved. Current Procedural Terminology ©2010 American Medical Association. All Rights Reserved. |
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