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Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.21n

Policy

Needle and non-needle electromyography (EMG) of the anal or urethral sphincter is considered medically necessary and, therefore, covered for the following indications:
  • As an initial diagnostic evaluation of an individual with an evacuation or voiding dysfunction (e.g., fecal incontinence, constipation, urinary incontinence, bladder outlet obstruction, detrusor sphincter dyssynergia, neurogenic conditions) that cannot be determined after an initial clinical evaluation (history and physical) and the needle and non-needle EMG is likely to affect the course of therapy (e.g., pelvic floor training, surgical intervention, pharmacologic intervention, biofeedback therapy or other clinically accepted interventions)
    • For cases of constipation, prior to the EMG:
      • Medications that can cause constipation should be discontinued.
      • Constipation secondary to other diseases should be excluded.
      • A trial of fiber and/or other laxatives should have been conducted.
  • For the repeat assessment of an individual with a confirmed diagnosis of anal or urethral sphincter dysfunction, or an indeterminate diagnosis of anal or urethral sphincter dysfunction, when the following conditions are present:
    • When there is a significant change in the signs and symptoms of evacuation or voiding dysfunction (e.g., fecal incontinence, constipation, recurrent urinary incontinence, bladder outlet obstruction, neurogenic conditions) that has not responded to medical intervention and cannot be determined by a clinical evaluation (history and physical)
    • When there are complications from the treatment of anal or urethral sphincter dysfunction
  • For the continued assessment of an individual with neurogenic conditions of the anal or urethral sphincter resulting from disorders such as, but not limited to, multiple sclerosis, spinal cord injury, paralysis, or motor neuron disease
    • For these individuals, EMG testing of the anal or urethral sphincter may be required up to two times a year.
PROFESSIONAL AND TECHNICAL REIMBURSEMENT FOR NEEDLE EMG
  • Only physicians (MD/DO) are eligible to receive reimbursement for the professional component of EMG. 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 EMG.
STATE OF NEW JERSEY PERFORMANCE OF NEEDLE EMG

In the state of New Jersey, as defined by the scope of practice regulations, only a physician may perform needle EMG studies.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agencies, therapies, other health care professionals, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request.

Documentation in the medical records must clearly demonstrate that the individual had signs and symptoms of an evacuation or voiding dysfunction. The documentation must verify that the EMG service was performed as billed.

Guidelines

Electromyography (EMG) performed as part of biofeedback therapy is inherent to the biofeedback service and should not be reported with Current Procedural Terminology (CPT) code 51784.

Other urodynamic tests, including cystometry, urethral profilometry, and uroflowmetry may be performed on the same date of service as an EMG study.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, EMG of the anal or urethral sphincter is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several EMG devices for use in the evaluation of evacuation dysfunction.

BILLING GUIDELINES

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

Electromyography (EMG) of the anal or urethral sphincter is a urodynamic study that quantitatively assesses the electrical activity from the striated muscles of the urethral or anal sphincter or from the perineal floor muscles. EMG provides objective data about the innervation to these muscles and the synchronization between the detrusor muscle of the bladder and the external sphincter; it is most useful to evaluate sphincter relaxation during voluntary detrusor contraction. EMG is used in the diagnosis and follow-up of known or suspected neurogenic (originating in nervous tissue) and non-neurogenic (originating in areas other than nervous tissue) conditions of the anal or urethral sphincters. An EMG of the anal or urethral sphincter can be performed using a needle electrode, a fine wire electrode, a surface electrode on the perianal skin, an anal plug, or an assembly of multiple-surface EMG electrodes placed in the anal canal.

EMG (needle and non-needle) of the anal or urethral sphincter is commonly used to evaluate conditions such as, but not limited to, the following:
  • Fecal incontinence
  • Constipation
  • Urinary incontinence
  • Bladder outlet obstruction (a blockage at the base of the bladder that reduces or prevents the flow of urine into the urethra)
  • Detrusor sphincter dyssynergia (a neurogenic abnormality that involves an impaired coordination between bladder contraction and sphincter relaxation)
  • Neurogenic conditions of the anal or urethral sphincter resulting from disorders such as, but not limited to, multiple sclerosis, spinal cord injury, paralysis, or motor neuron disease
An EMG alone gives useful information about sphincteric function. However, an EMG is more valuable when performed in conjunction with cystometry to determine whether the striated sphincter appropriately increases its activity during bladder filling and whether rest occurs normally before and during bladder contraction. EMG is useful in diagnosing detrusor sphincter dyssynergia, which can occur in individuals with neurogenic conditions such as multiple sclerosis, spinal cord injury, or other neurologic lesions. EMG is also valuable in conjunction with pressure-flow studies, which analyze detrusor pressure and flow rate during the voiding phase. EMG during pressure-flow studies is useful in diagnosing conditions such as detrusor sphincter dyssynergia, dysfunctional voiding (non-neurogenic), bladder outlet obstruction, or incontinence.

When injury to the sacral roots of the spinal cord is suspected, a separate study of the anal sphincter using needle EMG may be required, as this is the only muscle accessible to needle EMG examination that receives its innervation through these roots. Needle EMG of the anal sphincter may also be performed to assess the innervation and anatomic integrity of the sphincters. In addition, characteristics of neurogenic bladders can change with time and disease progression; therefore, re-evaluation may be needed when symptoms change despite medical intervention.

References

American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Recommended Policy for Electrodiagnostic M​edicine. [AANEM Web site]. January 2023. Available at: https://www.aanem.org/getmedia/04742e36-ce31-4990-ae3e-0fb27fbf5bd6/Recommended-Policy-for-Electrodiagnostic-Medicine.pdf​. Accessed March 3, 2023.

Bauer SB. Neurogenic bladder: etiology and assessment. Pediatr Nephrol. 2008;23(4):541-551.

Bharucha AE. Update of tests of colon and rectal structure and function. J Clin Gastroenterol.2006;40(2):96-103.

Dorflinger A, Monga A. Voiding dysfunction. Curr Opin Obstet Gynecol.2001;13(5):501-512.

Elneil S. Urinary retention in women and sacral neuromodulation. Int Urogynecol J Pelvic Floor Dysfunct. 2010;21Suppl 2:475-483.

Griffiths D, Kondo A, Bauer S, et al. Dynamic testing. In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence. Volume I: Basics & Evaluation. Paris, France: Health Publication Ltd; 2005: 587-673.

Heesakkers JP, Gerresten RR. Urinary incontinence sphincter functioning from a urological perspective. Digestion.2001;69(2):93-101.

Jasvinder C. Anal sphincter electromyography and sphincter function profiles technique. [eMedicine Web site]. 08/06/2019. Available at: http://emedicine.medscape.com/article/1948316-technique. Accessed March 3, 2023​.

Lefaucher JP. Neurophysiological testing in anorectal disorders. Muscle Nerve.2006;33(3):324-333.

Novitas Solutions, Inc. Local Coverage Article (LCA). A54095 Billing and Coding: Nerve Conduction Studies and Electromyography. 10/01/15. Revised 01/01/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=54095&ver=41&bc=0​. Accessed March 3, 20213.

Novitas Solutions, Inc. Local Coverage Article (LCA). A56530 Billing and Coding: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters. 05/16/19. Revised 01/01/2020.
Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56530&ver=12. Accessed March 3, 2023​.​

​Novitas Solutions, Inc. Local Coverage Determination (LCD). L34977: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters. 10/01/15. Revised 04/30/2020. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34977&ver=27&Date=10/30/2020&SearchType=Advanced&DocID=L34977&bc=KAAAAAIAAAAA&. Accessed March 3, 2023​​.
Novitas Solutions, Inc. Local Coverage Determination (LCD). L35081: Nerve conduction studies and electromyography. 10/01/15. Revised 10/31/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35081&ver=79&Date=10/30/2020&SearchType=Advanced&DocID=L35081&bc=KAAAAAIAAAAA&. Accessed March 3, 2023​.

Peterson AC, Webster GD. Urodynamic and videourodynamic evaluation of voiding dysfunction. In Campbell-Walsh's Urology, 9th edition. Philadelphia: WB Saunders, Chapter 28, 2007.

Podnar S. Neurophysiology of the neurogenic lower urinary tract disorders. Neurophysiol.2007;118(7):1423-1437.

Sakakibara R, Uchiyama T, Yamanishi T, et al. Sphincter EMG as a diagnostic tool in automomic disorders. Clin Auton Res.2009;19(1):20-31.

Scott SM, Gladman MA. Manometric, sensorimotor, and neurophysiologic evaluation of anorectal function. Gastroenterol Clin North Am.2008;37(3):511-538.

U.S. Food and Drug Administration (FDA). Center for Devices and Radiological Health. POLYGRAM NET™ Biofeedback Application. 510(k) summary. [FDA Web site]. 08/12/04. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf4/k041244.pdf. Accessed March 3, 2023​.

Coding

CPT Procedure Code Number(s)
51784, 51785
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
See Attachment A.
HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
0922 Other Diagnostic Services-Electromyogram


Coding and Billing Requirements

Policy History

9/30/2024
9/29/2023
07.03.21
Medical Policy Bulletin
Commercial
No