Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter

Policy #:07.03.21j

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


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.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

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 medicine. [AANEM Web site]. 08/30/2014. Available at:
https://www.aanem.org/getmedia/ed2143b6-917f-4218-b699-e682b18ad15d/2014_Recommended_Policy_EDX_Medicine-(1).pdf Accessed November 02, 2018.

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.

Dyro F. Urologic Management in Neurologic Disease [eMedicine Web site]. 11/08/2018. Available at: http://emedicine.medscape.com/article/453539-overview. Accessed November 11, 2018.

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. [eMedicine Web site]. 12/19/2016 Available at: http://emedicine.medscape.com/article/1948316-technique. Accessed November 02, 2018.

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

Novitas Solutions, Inc. Local Coverage Determination (LCD).L35081: Nerve conduction studies and electromyography. [Novitas Solutions, Inc. Web site]. 10/01/15. Revised 10/01/2018. Available at: https://www.cms.gov/medicare-coverage-database/license/cpt-license.aspx?from=~/overview-and-quick-search.aspx&npage=/medicare-coverage-database/details/lcd-details.aspx&LCDId=35081&ContrId=332&ver=66&ContrVer=1&CntrctrSelected=332*1&Cntrctr=332&s=All&DocType=All&bc=AAAAAAQAAAAA&. Accessed November 02, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L34977: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters. [Novitas Solutions, Inc. Web site]. 10/01/15. Revised 10/01/2016. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34977&ver=13&name=314*1&UpdatePeriod=804&bc=AAAAEAAAAAAA&. Accessed November 02, 2018.

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.

US 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
November 02, 2018.






Coding

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.

CPT Procedure Code Number(s)

51784, 51785


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


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


Cross References

Attachment A: Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
Description: ICD-10-CM codes




Policy History

07.03.21j:
11/21/2018This policy has been reviewed and reissued to communicate the Company's continuing position on Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter.
10/01/2018This version of the policy will become effective 10/01/2018. The following ICD-10 codes have been added to the policy: N35.016, N35.116, N35.811, N35.812, N35.813, N35.814, N35.816, N35.819, N35.82, N35.911, N35.912, N35.913, N35.914, N35.916, N35.919, N35.92, N99.116. The following ICD-10 codes have been termed from the policy: N35.9.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: 11/21/2018

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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.