Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA07.050f


Attachment:D

Policy #:MA07.050f

Description:ICD-10 Codes

Title:Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)


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.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.


THE FOLLOWING CODES REPRESENT INDICATIONS THAT SUPPORT MEDICAL NECESSITY
ICD-10 Code Narrative
I69.042Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.043Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.044Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.133Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right non-dominant side
I69.134Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.141Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.142Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left dominant side
I69.143Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right non-dominant side
I69.144Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.233Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.234Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.241Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.242Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.243Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.244Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.333Monoplegia of upper limb following cerebral infarction affecting right non-dominant side
I69.334Monoplegia of upper limb following cerebral infarction affecting left non-dominant side
I69.341Monoplegia of lower limb following cerebral infarction affecting right dominant side
I69.342Monoplegia of lower limb following cerebral infarction affecting left dominant side
I69.343Monoplegia of lower limb following cerebral infarction affecting right non-dominant side
I69.344Monoplegia of lower limb following cerebral infarction affecting left non-dominant side
I69.833Monoplegia of upper limb following other cerebrovascular disease affecting right non-dominant side
I69.834Monoplegia of upper limb following other cerebrovascular disease affecting left non-dominant side
I69.841Monoplegia of lower limb following other cerebrovascular disease affecting right dominant side
I69.842Monoplegia of lower limb following other cerebrovascular disease affecting left dominant side
I69.843Monoplegia of lower limb following other cerebrovascular disease affecting right non-dominant side
I69.844Monoplegia of lower limb following other cerebrovascular disease affecting left non-dominant side
I69.933Monoplegia of upper limb following unspecified cerebrovascular disease affecting right non-dominant side
I69.934Monoplegia of upper limb following unspecified cerebrovascular disease affecting left non-dominant side
I69.941Monoplegia of lower limb following unspecified cerebrovascular disease affecting right dominant side
I69.942Monoplegia of lower limb following unspecified cerebrovascular disease affecting left dominant side
I69.943Monoplegia of lower limb following unspecified cerebrovascular disease affecting right non-dominant side
I69.944Monoplegia of lower limb following unspecified cerebrovascular disease affecting left non-dominant side
I95.1Orthostatic hypotension
J38.00Paralysis of vocal cords and larynx, unspecified
J38.01Paralysis of vocal cords and larynx, unilateral
J38.02Paralysis of vocal cords and larynx, bilateral
J38.5Laryngeal spasm
J38.7Other diseases of larynx
K22.0Achalasia of cardia
M05.411Rheumatoid myopathy with rheumatoid arthritis of right shoulder
M05.412Rheumatoid myopathy with rheumatoid arthritis of left shoulder
M05.421Rheumatoid myopathy with rheumatoid arthritis of right elbow
M05.422Rheumatoid myopathy with rheumatoid arthritis of left elbow
M05.431Rheumatoid myopathy with rheumatoid arthritis of right wrist
M05.432Rheumatoid myopathy with rheumatoid arthritis of left wrist
M05.441Rheumatoid myopathy with rheumatoid arthritis of right hand
M05.442Rheumatoid myopathy with rheumatoid arthritis of left hand
M05.451Rheumatoid myopathy with rheumatoid arthritis of right hip
M05.452Rheumatoid myopathy with rheumatoid arthritis of left hip
M05.461Rheumatoid myopathy with rheumatoid arthritis of right knee
M05.462Rheumatoid myopathy with rheumatoid arthritis of left knee
M05.471Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
M05.472Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
M05.49Rheumatoid myopathy with rheumatoid arthritis of multiple sites
M05.511Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder
M05.512Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
M05.521Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow
M05.522Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
M05.531Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist
M05.532Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
M05.541Rheumatoid polyneuropathy with rheumatoid arthritis of right hand
M05.542Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
M05.551Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
M05.552Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
M05.561Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
M05.562Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
M05.571Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
M05.572Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
M05.59Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
M21.071Valgus deformity, not elsewhere classified, right ankle
M21.072Valgus deformity, not elsewhere classified, left ankle
M21.079Valgus deformity, not elsewhere classified, unspecified ankle
M21.171Varus deformity, not elsewhere classified, right ankle
M21.172Varus deformity, not elsewhere classified, left ankle
M21.179Varus deformity, not elsewhere classified, unspecified ankle
M21.331Wrist drop, right wrist
M21.332Wrist drop, left wrist
M21.339Wrist drop, unspecified wrist
M21.371Foot drop, right foot
M21.372Foot drop, left foot
M21.379Foot drop, unspecified foot
M21.511Acquired clawhand, right hand
M21.512Acquired clawhand, left hand
M21.519Acquired clawhand, unspecified hand
M21.531Acquired clawfoot, right foot
M21.532Acquired clawfoot, left foot
M21.539Acquired clawfoot, unspecified foot
M21.541Acquired clubfoot, right foot
M21.542Acquired clubfoot, left foot
M21.549Acquired clubfoot, unspecified foot
M21.6X1Other acquired deformities of right foot
M21.6X2Other acquired deformities of left foot
M21.6X9Other acquired deformities of unspecified foot
M21.831Other specified acquired deformities of right forearm
M21.832Other specified acquired deformities of left forearm
M21.839Other specified acquired deformities of unspecified forearm
M21.961Unspecified acquired deformity of right lower leg
M21.962Unspecified acquired deformity of left lower leg
M21.969Unspecified acquired deformity of unspecified lower leg
M25.78Osteophyte, vertebrae
M33.00Juvenile dermatomyositis, organ involvement unspecified
M33.01Juvenile dermatomyositis with respiratory involvement
M33.02Juvenile dermatomyositis with myopathy
M33.09Juvenile dermatomyositis with other organ involvement
M33.10Other dermatomyositis, organ involvement unspecified
M33.11Other dermatomyositis with respiratory involvement
M33.12Other dermatomyositis with myopathy
M33.19Other dermatomyositis with other organ involvement
M33.20Polymyositis, organ involvement unspecified
M33.21Polymyositis with respiratory involvement
M33.22Polymyositis with myopathy
M33.29Polymyositis with other organ involvement
M33.90Dermatopolymyositis, unspecified, organ involvement unspecified
M33.91Dermatopolymyositis, unspecified with respiratory involvement
M33.92Dermatopolymyositis, unspecified with myopathy
M33.99Dermatopolymyositis, unspecified with other organ involvement
M35.3Polymyalgia rheumatica
M35.4Diffuse (eosinophilic) fasciitis
M35.8Other specified systemic involvement of connective tissue
M36.0Dermato(poly)myositis in neoplastic disease
M41.112Juvenile idiopathic scoliosis, cervical region
M41.113Juvenile idiopathic scoliosis, cervicothoracic region
M41.114Juvenile idiopathic scoliosis, thoracic region
M41.115Juvenile idiopathic scoliosis, thoracolumbar region
M41.116Juvenile idiopathic scoliosis, lumbar region
M41.117Juvenile idiopathic scoliosis, lumbosacral region
M41.119Juvenile idiopathic scoliosis, site unspecified
M41.122Adolescent idiopathic scoliosis, cervical region
M41.123Adolescent idiopathic scoliosis, cervicothoracic region
M41.124Adolescent idiopathic scoliosis, thoracic region
M41.125Adolescent idiopathic scoliosis, thoracolumbar region
M41.126Adolescent idiopathic scoliosis, lumbar region
M41.127Adolescent idiopathic scoliosis, lumbosacral region
M41.129Adolescent idiopathic scoliosis, site unspecified
M41.20Other idiopathic scoliosis, site unspecified
M41.22Other idiopathic scoliosis, cervical region
M41.23Adolescent idiopathic scoliosis, cervicothoracic region
M41.24Other idiopathic scoliosis, thoracic region
M41.25Other idiopathic scoliosis, thoracolumbar region
M41.26Other idiopathic scoliosis, lumbar region
M41.27Other idiopathic scoliosis, lumbosacral region
M43.00Spondylolysis, site unspecified
M43.01Spondylolysis, occipito-atlanto-axial region
M43.02Spondylolysis, cervical region
M43.03Spondylolysis, cervicothoracic region
M43.04Spondylolysis, thoracic region
M43.05Spondylolysis, thoracolumbar region
M43.06Spondylolysis, lumbar region
M43.07Spondylolysis, lumbosacral region
M43.08Spondylolysis, sacral and sacrococcygeal region
M43.09Spondylolysis, multiple sites in spine
M43.10Spondylolisthesis, site unspecified
M43.11Spondylolisthesis, occipito-atlanto-axial region
M43.12Spondylolisthesis, cervical region
M43.13Spondylolisthesis, cervicothoracic region
M43.14Spondylolisthesis, thoracic region
M43.15Spondylolisthesis, thoracolumbar region
M43.16Spondylolisthesis, lumbar region
M43.17Spondylolisthesis, lumbosacral region
M43.18Spondylolisthesis, sacral and sacrococcygeal region
M43.19Spondylolisthesis, multiple sites in spine
M43.6Torticollis
M46.41Discitis, unspecified, occipito-atlanto-axial region
M46.42Discitis, unspecified, cervical region
M46.43Discitis, unspecified, cervicothoracic region
M46.44Discitis, unspecified, thoracic region
M46.45Discitis, unspecified, thoracolumbar region
M46.46Discitis, unspecified, lumbar region
M46.47Discitis, unspecified, lumbosacral region
M47.011Anterior spinal artery compression syndromes, occipito-atlanto-axial region
M47.012Anterior spinal artery compression syndromes, cervical region
M47.013Anterior spinal artery compression syndromes, cervicothoracic region
M47.014Anterior spinal artery compression syndromes, thoracic region
M47.015Anterior spinal artery compression syndromes, thoracolumbar region
M47.016Anterior spinal artery compression syndromes, lumbar region
M47.019Anterior spinal artery compression syndromes, site unspecified
M47.021Vertebral artery compression syndromes, occipito-atlanto-axial region
M47.022Vertebral artery compression syndromes, cervical region
M47.029Vertebral artery compression syndromes, site unspecified
M47.10Other spondylosis with myelopathy, site unspecified
M47.11Other spondylosis with myelopathy, occipito-atlanto-axial region
M47.12Other spondylosis with myelopathy, cervical region
M47.13Other spondylosis with myelopathy, cervicothoracic region
M47.14Other spondylosis with myelopathy, thoracic region
M47.15Other spondylosis with myelopathy, thoracolumbar region
M47.16Other spondylosis with myelopathy, lumbar region
M47.20Other spondylosis with radiculopathy, site unspecified
M47.21Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22Other spondylosis with radiculopathy, cervical region
M47.23Other spondylosis with radiculopathy, cervicothoracic region
M47.24Other spondylosis with radiculopathy, thoracic region
M47.25Other spondylosis with radiculopathy, thoracolumbar region
M47.26Other spondylosis with radiculopathy, lumbar region
M47.27Other spondylosis with radiculopathy, lumbosacral region
M47.28Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812Spondylosis without myelopathy or radiculopathy, cervical region
M47.813Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.814Spondylosis without myelopathy or radiculopathy, thoracic region
M47.815Spondylosis without myelopathy or radiculopathy, thoracolumbar region
M47.816Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.818Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M47.819Spondylosis without myelopathy or radiculopathy, site unspecified
M47.891Other spondylosis, occipito-atlanto-axial region
M47.892Other spondylosis, cervical region
M47.893Other spondylosis, cervicothoracic region
M47.894Other spondylosis, thoracic region
M47.895Other spondylosis, thoracolumbar region
M47.896Other spondylosis, lumbar region
M47.897Other spondylosis, lumbosacral region
M47.898Other spondylosis, sacral and sacrococcygeal region
M47.899Other spondylosis, site unspecified
M47.9Spondylosis, unspecified
M48.00Spinal stenosis, site unspecified
M48.01Spinal stenosis, occipito-atlanto-axial region
M48.02Spinal stenosis, cervical region
M48.03Spinal stenosis, cervicothoracic region
M48.04Spinal stenosis, thoracic region
M48.05Spinal stenosis, thoracolumbar region
M48.061 Spinal stenosis, lumbar region without neurogenic claudication
M48.062 Spinal stenosis, lumbar region with neurogenic claudication
M48.07Spinal stenosis, lumbosacral region
M48.08Spinal stenosis, sacral and sacrococcygeal region
M48.10Ankylosing hyperostosis [Forestier], site unspecified
M48.11Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region
M48.12Ankylosing hyperostosis [Forestier], cervical region
M48.13Ankylosing hyperostosis [Forestier], cervicothoracic region
M48.14Ankylosing hyperostosis [Forestier], thoracic region
M48.15Ankylosing hyperostosis [Forestier], thoracolumbar region
M48.16Ankylosing hyperostosis [Forestier], lumbar region
M48.17Ankylosing hyperostosis [Forestier], lumbosacral region
M48.18Ankylosing hyperostosis [Forestier], sacral and sacrococcygeal region
M48.19Ankylosing hyperostosis [Forestier], multiple sites in spine
M48.20Kissing spine, site unspecified
M48.21Kissing spine, occipito-atlanto-axial region
M48.22Kissing spine, cervical region
M48.23Kissing spine, cervicothoracic region
M48.24Kissing spine, thoracic region
M48.25Kissing spine, thoracolumbar region
M48.26Kissing spine, lumbar region

Version Effective Date: 10/01/2019
Version Issued Date: 10/02/2019
Version Reissued Date: 11/22/2019

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.