Contractor Information LCD Informationepipg.com/billing-office-resources/pdf/Nerve-Conduction... · 2018-10-16 · Nerve conduction studies are of two general types: sensory and motor

Contractor NameNovitas Solutions, Inc.

Contract Number04412

Contract TypeA and B MAC

JurisdictionJ - H

LCD IDL35081

Original ICD-9 LCD IDL29547

LCD TitleNerve Conduction Studies and Electromyography

AMA CPT / ADA CDT / AHA NUBC Copyright StatementCPT only copyright 2002-2014 American MedicalAssociation. All Rights Reserved. CPT is a registeredtrademark of the American Medical Association.Applicable FARS/DFARS Apply to Government Use. Feeschedules, relative value units, conversion factorsand/or related components are not assigned by theAMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly orindirectly practice medicine or dispense medicalservices. The AMA assumes no liability for datacontained or not contained herein.

The Code on Dental Procedures and Nomenclature(Code) is published in Current Dental Terminology(CDT). Copyright © American Dental Association. Allrights reserved. CDT and CDT-2010 are trademarks ofthe American Dental Association.

JurisdictionTexas

Original Effective DateFor services performed on or after 10/01/2015

Revision Effective DateFor services performed on or after 10/01/2015

Revision Ending DateN/A

Retirement DateN/A

Notice Period Start DateN/A

Notice Period End DateN/A

FUTURE Local Coverage Determination (LCD):Nerve Conduction Studies and Electromyography (L35081)

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Please note: Future Effective Date.

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LCD InformationDocument Information

Printed on 9/21/2015. Page 1 of 40

https://www.cms.gov/medicare-coverage-database/staticpages/contractor-details.aspx?ContrId=338&ver=1

UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONSMANUAL, 2014, is copyrighted by American HospitalAssociation (“AHA”), Chicago, Illinois. No portion ofOFFICIAL UB-04 MANUAL may be reproduced, sorted ina retrieval system, or transmitted, in any form or byany means, electronic, mechanical, photocopying,recording or otherwise, without prior express, writtenconsent of AHA.” Health Forum reserves the right tochange the copyright notice from time to time uponwritten notice to Company.

CMS National Coverage Policy Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that noMedicare payment shall be made for items or services which are not reasonable and necessary for the diagnosisor treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider forany claim that lacks the necessary information to process the claim.

CMS Internet-Only Manual (IOM), Publication 100-3, Medicare National Coverage Determinations Manual, Chapter1, Section 160.23 concludes after reconsideration (2004) that there continues to be insufficient scientific orclinical evidence to consider the sNCT test and the device used in performing this test as reasonable andnecessary within the meaning of section 1862(a)(1)(A) of the law.

Program Memorandum B-01-28 dated April 19, 2001, Medicare Carriers Manual Change Request 1756, datedSeptember 27, 2001

42 CFR Section 410.32

Federal Register Vol. 62, 59047

CMS IOM Publication 100-2. Chapter 15, Section 80

Transmittal 2663 Change Request 8169 April Update to the CY 2013 Medicare Physician Fee Schedule Database(MPFSDB)

Coverage GuidanceCoverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) asif they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment dataanalysis and subsequent medical review audits.

Electromyography (EMG) is the study and recording of intrinsic electrical properties of skeletal muscles. This iscarried out with a needle electrode. Generally, the needles are of two types: monopolar or concentric. There is arequirement for ongoing real-time clinical diagnostic evaluation, especially during EMG examination. Also, EMGexamination is invasive. Needle placement in the exact muscle of interest is essential. It requires needleexploration near vital structures as the pleura, femoral neurovascular bundle, peritoneum, intraspinal spaces,carotid artery, orbit and brachial plexus. Risk of infection from AIDS, Hepatitis B-E, Creutzfeldt-Jakobencephalopathy, and hemorrhage from anticoagulation can be managed by proper techniques.

Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulationwhich are recordable over the nerve or from an innervated muscle. With this technique, responses are measuredbetween two sites of stimulation, or between a stimulus and a recording site.

Nerve conduction studies are of two general types: sensory and motor. Either surface or needle electrodes can beused to stimulate the nerve or record the response. Axonal damage or dysfunction generally results in loss ofnerve or muscle potential response amplitude; whereas, demyelination leads to prolongation of conduction timeand slowing of conduction velocity.

Obtaining and interpreting NCS results requires extensive interaction between the performing qualified healthcare professional and patient, and is most effective when both obtaining raw data and interpretation are


1. the myelin sheath (Schwann cell derived insulation covering an axon), and2. the axon (an extension of neuronal cell body) of a nerve.

performed concurrently on a real-time basis.

Results of the NCS reflect on the integrity and function of:

Interruption of axon and dysfunction of myelin will both affect NCS results.

EMG is undertaken together with nerve conduction studies (NCS). Unlike NCS, however, EMG testing relies onboth auditory and visual feedback to the electromyographer. This testing is also invasive in that it requires needleelectrode insertion and adjustment at multiple sites, and at times, anatomically critical sites. As in NCS, duringEMG studies, the electromyographer depends on ongoing real-time interpretation based knowledge of the clinicaldiagnoses being evaluated to decide whether to continue, modify, or conclude a test. This process requiresknowledge of anatomy, physiology and neuromuscular diseases.

There may be instances where questions about an indication or need for a study will arise. The clinical history andexamination, carried out before the study, must always describe and document clearly and comprehensibly theneed for the planned test. A "rule-out" diagnosis is typically not acceptable. The Contractor is cognizant of thefact that patients are not always referred with a definite diagnosis in mind. Often, pain, paresthesia, or weaknessin an extremity is the reason for an NCS or EMG. These common symptoms result not only from axonal andmyelin dysfunction but also from systemic, non-neurological illnesses. EMG and NCV may help in making thisdistinction. Therefore, symptom-based diagnoses such as "pain in limb," weakness, disturbance in skin sensationor "paresthesia" are acceptable provided the clinical assessment unequivocally supports the need for a study. Tocite but one example of many, an EMG or NCS is irrelevant as a first order diagnostic test for limb pain resultingfrom immediate antecedent trauma or acute bone injury.

Both EMGs and NCSs are required for a clinical diagnosis of peripheral nervous system disorders. EMG resultsreflect on the integrity of the functioning connection between a nerve and its innervated muscle and also on theintegrity of a muscle itself. Performance of one does not eliminate the need for the other. The intensity andextent of testing with EMG and NCS are matters of clinical judgment developed after the initial pre-testevaluation, and later modified during the testing procedure.

The electrodiagnostic evaluation is actually an extension of the neurologic portion of the physical examination.Both require a detailed knowledge of a patient and his/her disease. Training in the performance ofelectrodiagnostic procedures, in isolation without awareness and ability to diagnose and manage neuromusculardiseases, is not always adequate for electrodiagnostic consultation. Recognition and experience in themanagement of disparate diseases that produce common electrodiagnostic findings may be necessary. Forexample, EMG-NCS findings may overlap in the following pairs of disorders: inflammatory myopathies and ALS,ALS and multi-level radiculopathies, myotonia of channelopathies (periodic paralyses) and myotonic dystrophies,focal neuropathies such as Carpal Tunnel Syndrome and proximal plexopathies. Other instances where knowledgeof disease behavior is crucial are Chronic Inflammatory Demyelinating Neuropathy (CIDP) and Multifocal MotorNeuropathy. These entities display electrodiagnostic features that resemble generalized polyneuropathies.Neuromuscular transmission disorders require separation based on clinical presentation and electrical features.Treatment will depend on differentiating among them. Without awareness of the disease spectrum, diagnosissolely by EMG-NCS findings may be either wrong or detrimental to the patient.

In summary, axonal and muscle involvement are most sensitively detected by EMGs, and myelin and axonalinvolvement are best detected by NCSs.

Electromyography (EMG)

EMG results reflect not only on the integrity of the functioning connection between a nerve and its innervatedmuscle but also on the integrity of a muscle itself. The axon innervating a muscle is primarily responsible for themuscle's volitional contraction, survival, and trophic functions. Thus, interruption of the axon will alter the EMG. Afew prime examples of neurologic conditions in which EMG is potentially helpful, although not an all-inclusivelisting, are disc disease producing spinal nerve dysfunction, advanced nerve compression in peripheral lesions,Amyotrophic Lateral Sclerosis (ALS), and polyneuropathy, etc. After an acute neurogenic lesion, it is important tonote that EMG changes may not appear for several days to weeks in the innervated muscles.

Primary muscle diseases such as polymyositis will also alter a normal EMG pattern. Myotonic disorders may showa pattern of spontaneous repetitive discharges on needle exploration.

Neurogenic disorders can be distinguishable from myopathic disorders by a carefully performed EMG. Forexample, both polymyositis and ALS (Amyotrophic Lateral Sclerosis) produce weakness. The former carries a verydifferent prognosis and treatment than the latter. An EMG is very valuable in making this distinction. Similarly,


1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions.2. Radiculopathy - cervical, lumbosacral.3. Mono/polyneuropathy - metabolic, degenerative, hereditary.4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies.5. Plexopathy - idiopathic, trauma, infiltration.6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here.7. At times, immediately prior to Botulinum A toxin injection, for localization.8. At times, immediately prior to injection of phenol or other substances for nerve blocking or

chemodenervation.

• exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions• definitive diagnostic conclusions based on paraspinal EMG in regions bearing scar of past surgeries (e.g.,

previous laminectomies)• pattern-setting limited limb muscle examinations, without paraspinal muscle testing for a diagnosis of

radiculopathy• EMG testing shortly after trauma, before EMG abnormalities would have reasonably had time to develop• surface and macro EMG (95999) - This is not the same as a conventional EMG and involves the use of a

probe that is passed over the surface of the skin in order to measure electrical muscle activity. Thismethod of EMG testing is considered investigational and is not a covered service. Surface and macro EMGswill be denied as not medically necessary. An exception may be made for the use of surface EMG for CPTCode 51784 when used in accordance with LCD L34977 (Anorectal Manometry, Anal Electromyography,and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters). See that documentfor further coverage and limitations.

• multiple uses of EMG in the same patient at the same location of the same limb for the purpose ofoptimizing botulinum toxin injections.

1. Focal neuropathies or compressive lesions such as carpal tunnel syndrome, ulnar neuropathies or rootlesions, for localization.

2. Traumatic nerve lesions, for diagnosis and prognosis.3. Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic, metabolic or

immune.4. Repetitive nerve stimulation in diagnosis of neuromuscular junction disorders such as myasthenia gravis,

myasthenic syndrome.5. There may be other instances, not detailed here, where NCS may be of use. Not all possible or potential

indications are addressed here.

classification of nerve trauma into axonal vs. demyelinating categories, with corresponding differences inprognoses, are possible with EMG. Below is a list of common disorders where an EMG, in tandem with properlyconducted NCS, will be helpful in diagnosis:

There may be other instances, not detailed here, where EMG may be of use.

Use of EMG with Botulinum Toxin Injection

EMG may be used to optimize the anatomic location of botulinum toxin injection. It is expected there will be onestudy performed per anatomic location of injection, if needed.

The necessity and reasonableness of the following uses of EMG studies have not been established:

Nerve Conduction Studies (NCS)

The dichotomy into axonal and demyelinating neuropathies provides a practical means of correlating electricalabnormalities with major pathophysiologic changes in the nerve. Electrical studies can be of help in localization ofan abnormality and in distinguishing one variety of neuropathy from another: for example, diffuse vs. multifocal;axonal vs. demyelinating. Such distinction has diagnostic value. Specific classification of nerve injuries intoneuropraxia and axonotmesis can be made on the basis of conduction studies and electromyography. Suchclassification has a bearing on prognosis and treatment.

The following definitions are from the American Association of Neuromuscular Electrodiagnostic MedicineRecommended Policy for Electrodiagnostic Medicine

http://www.aan.com/globals/axon/assets/4061.pdf


a. Motor - Motor NCSs are performed by applying electrical stimulation at various points along the course ofa motor nerve while recording the electrical response from an appropriate muscle. Response parametersinclude amplitude, latency, configuration, and motor conduction velocity.

b. Sensory - Sensory NCSs are performed by applying electrical stimulation near a nerve and recording theresponse from a distant site along the nerve. Response parameters include amplitude, latency andconfiguration.

c. Mixed NCSs are performed by applying electrical stimulation near a nerve containing both motor andsensory fibers (a mixed nerve) and recording from a different location along that nerve that also containsboth motor and sensory nerve fibers. Response parameters include amplitude, latency, configuration, andmotor conduction velocity."

d. Nerve conduction studies performed using automated devices (for example devices such as NC-stat®System) cannot support testing of other locations and other nerves as needed depending on theconcurrent results of testing. Please refer to Local Coverage Article for Nerve Conductions Studies andElectromyography (A54095) for coding instructions when reporting these services..

"The stimulation of nerves is similar across all NCSs; the characteristics of motor, sensory, and mixed NCSs aredifferent and are discussed separately below. In each case, an appropriate nerve is stimulated and recording ismade either from the appropriate nerves or from muscle supplied by the motor nerve.

When the beneficiary has a high (more than 80%) pre-test or a prior probability for having the diagnosis ofCarpal Tunnel Syndrome, the NC-stat® System (alone) will be considered medically reasonable and necessary,for Carpal Tunnel Syndrome. All other ICD-10 codes will be denied as not medically necessary. One service perarm, per beneficiary, per lifetime will be allowed. (Refer to Local Coverage Article A54095 for correct coding.

Nerve conduction studies performed independent of needle electromyography (EMG) may only provide a portionof the information needed to diagnose muscle, nerve root, and most nerve disorders. When the nerve conductionstudy (NCS) is used on its own without integrating needle EMG findings, or when an individual relies solely on areview of NCS data, the results can be misleading and important diagnoses may be missed.

In most instances, both NCS and EMG are necessary to perform diagnostic testing. While a provider may chooseto perform just a NCS, when performed alone it will be considered to be a screening exam. The only exception tothis is a situation where a provider may consider it appropriate to perform a NCS without doing an EMG for thediagnosis of carpal tunnel syndrome with a high pre-test probability that has yet to be confirmed.

It is often also valuable to test conduction status in proximal segments of peripheral nerves. This assessment canbe accomplished by H-reflex, F-wave and blink reflex testing. These proximal segments include the first severalcentimeters of a compound nerve emerging from the spinal cord or brainstem. H-reflex, F-waves and Blink reflextesting accomplish this task better than distal NCS. Current evidence in standard peer-reviewed medical journalsdoes not support the use of F waves, in isolation, to diagnose radiculopathy. This is to be contrasted with theinvestigation of distal peripheral nerves, which is accomplished by nerve conduction studies generallyaccompanied by EMG.

Each descriptor (code) from codes 95907, 95908, 95909, 95910, 95911, 95912, and 95913 can be reimbursedonly once per nerve, or named branch of a nerve, regardless of the number of sites tested or the number ofmethods used on that nerve. For instance, testing the ulnar nerve at wrist, forearm, below elbow, above elbow,axilla and supraclavicular regions will all be considered as a single nerve. Motor and sensory nerve testing areconsidered separate tests.

Screening testing for polyneuropathy of diabetes or end-stage renal disease (ESRD) is NOT covered.Testing for the sole purpose of monitoring disease intensity or treatment efficacy in these two conditions is alsonot covered.

Psychophysical measurements (current, vibration, thermal perceptions), even though they may involvedelivery of a stimulus, are considered to be part of the physical exam and may not be billed as a separateservice.

Current Perception Threshold/Sensory Nerve Conduction Threshold Test (sNCT) is not covered byMedicare. This procedure is different and distinct from assessment of nerve conduction velocity, amplitude andlatency. It is also different from short-latency somatosensory evoked potentials. Codes designated for elicitingnerve conduction velocity, latency or amplitude, and those designed for short latency evoked potentials are not tobe used for sNCT. The sNCT has a unique code G0255: Effective October 1, 2002, CMS initially concluded thatthere was insufficient scientific or clinical evidence to consider the sNCT test and the device used in performingthis test reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. Therefore, sNCT wasnoncovered. Based on a reconsideration [in March, 2004] of current Medicare policy for sNCT, CMS concludes thatthere continues to be insufficient scientific or clinical evidence to consider the sNCT test and the device used inperforming this test as reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. CMS


• Safe and effective.

Publication 100-3, Medicare National Coverage Issues Manual, Chapter 1, Section 160.23

Examination using portable hand-held devices, or devices which are incapable of real-time wave-form display andanalysis and incapable of both NCS and EMG testing, will be included in the E/M service. They will not be paidseparately. Examples include: The Axon II or delta fiber analysis testing and/or machines with other names.

Nerve conduction studies must provide a number of response parameters in a real-time fashion to facilitateprovider interpretation. Those parameters include amplitude, latency, configuration and conduction velocity.Medicare does not accept diagnostic studies that do not provide this information or those that provide delayedinterpretation as substitutes for nerve conduction studies. Raw measurement data obtained and transmitted trans-telephonically or over the Internet, therefore, does not qualify for the payment of the electrodiagnostic servicecodes included in this LCD.

Medicare does not expect to receive claims for nerve conduction testing accomplished with discriminatory devicesthat use fixed anatomic templates and computer-generated reports used as an adjunct to physical examinationroutinely on all patients.

EMG/NCS studies will not be covered when provided in the home of the beneficiary.

Guidelines about proper qualifications for qualified health care professionals performing electrodiagnosticevaluations have been developed and published by AANEM (American Association of Neuromuscular andElectrodiagnostic Medicine) and other medical organizations, including the AMA, the American Academy ofNeurology, the American Academy of Physical Medicine and Rehabilitation, American Neurological Association, theAmerican Board of Physical Therapy Specialties (ABPTS) in Clinical Electrophysiology, and the Department ofVeterans Affairs.

Novitas Solutions, Inc expects healthcare professionals who perform electrodiagnostic (ED) testing will beappropriately trained and/or credentialed, either by a formal residency/fellowship program, certification by anationally recognized organization or by an accredited post-graduate training course covering anatomy,neurophysiology and forms of electrodiagnostics (including both NCS and EMG) acceptable to this Contractor, inorder to provide the proper testing and assessment of the patient's condition and appropriate safety measures. Itwould be highly unlikely that this training and/or credentialing is possessed by providers other than Neurologists,or Physical Medicine and Rehabilitation physicians.

Physical Therapists Performing EMGs

Nerve conduction code 95905 does not have levels of supervision 21, 22, 6a, 66, 77 or 7a assigned to it and istherefore not allowed by Physical Therapists.

Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Procedures Indicatorsadjusted to 7A effective 01/01/2013 (CR 8169). Therefore, if authorized by state law, Physical Therapists areallowed the technical portion and professional component of the test according to the description of 7A.

Needle electromyographic (EMG) codes 95860-95872 and 95885-95887 have the designation 6A. Therefore, ifauthorized by state law, Physical Therapists are allowed the technical portion of the test according to thedescription of 6A.

Note: Please refer to Local Coverage Article, A54095 for additional information regarding supervision levels.

For outpatient settings other than Comprehensive Outpatient Rehabilitation Facility (CORF)s, references to"physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialistsand physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order andestablish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII ofthe Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.) Eachpractitioner must provide only those services within the scope of practice for each state.

Italicized and/or quoted material is excerpted from the American Medical Association, Current ProceduralTerminology (CPT) codes.

As published in CMS IOM 100-08, Chapter 13, Section 13.5.1, (this is not bolded) in order to be covered underMedicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe thecircumstances under which the proposed LCD for the service is considered reasonable and necessary underSection 1862 (a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractordetermines that the service is:


• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with datesof service on or after September 19, 2000, that meet the requirements of the Clinical Trails NCD areconsidered reasonable and necessary).

• Appropriate, including the duration and frequency that is considered appropriate for the services, in termsof whether it is:

◦ Furnished in accordance with accepted standards of medical practice for the diagnosis or treatmentof the patient's condition or to improve the function of a malformed body member.

◦ Furnished in a setting appropriate to the patient's medical needs and condition.◦ Ordered and furnished by qualified personnel.◦ One that meets, but does not exceed, the patient's medical needs.◦ At least as beneficial as an existing and available medically appropriate alternative.

012x Hospital Inpatient (Medicare Part B only)013x Hospital Outpatient021x Skilled Nursing - Inpatient (Including Medicare Part A)022x Skilled Nursing - Inpatient (Medicare Part B only)023x Skilled Nursing - Outpatient071x Clinic - Rural Health083x Ambulatory Surgery Center085x Critical Access Hospital

0920 Other Diagnostic Services - General Classification0922 Other Diagnostic Services - Electromyelgram0929 Other Diagnostic Services - Other Diagnostic Service

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Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of allBill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equallyto all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to reportthis service. In most instances Revenue Codes are purely advisory; unless specified in the policy servicesreported under other Revenue Codes are equally subject to this coverage determination. Complete absence of allRevenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed toapply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCScodes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all BillType and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and RevenueCodes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims ProcessingManual, for further guidance.

CPT/HCPCS CodesGroup 1 Paragraph: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Electromyography (EMG)

Note: for coverage indications and limitations of CPT code 51785 (needle electromyography studies (EMG) ofanal or urethral sphincter, any technique) refer to LCD L34977. The certification and supervision criteria for


92265 Eye muscle evaluation95860 Muscle test one limb95861 Muscle test 2 limbs95863 Muscle test 3 limbs95864 Muscle test 4 limbs95865 Muscle test larynx95866 Muscle test hemidiaphragm95867 Muscle test cran nerv unilat95868 Muscle test cran nerve bilat95869 Muscle test thor paraspinal95870 Muscle test nonparaspinal95872 Muscle test one fiber95874 Guide nerv destr needle emg95885 Musc tst done w/nerv tst lim95886 Musc test done w/n test comp95887 Musc tst done w/n tst nonext

95873 Guide nerv destr elec stim95905 Motor &/ sens nrve cndj test95907 Nvr cndj tst 1-2 studies95908 Nrv cndj tst 3-4 studies95909 Nrv cndj tst 5-6 studies95910 Nrv cndj test 7-8 studies95911 Nrv cndj test 9-10 studies95912 Nrv cndj test 11-12 studies95913 Nrv cndj test 13/> studies95933 Blink reflex test95937 Neuromuscular junction test95999 Neurological procedure

G0255 Current percep threshold tst

ICD-10Codes Description

A05.1 Botulism food poisoning

physical therapists in this policy do, however, apply to this code.

Group 1 Codes:

Group 2 Paragraph: Nerve Conduction Studies (NCS)

Note: For coverage indications and limitations for 95937 see LCD L34996 (Neuromuscular Junction Testing). Allother qualifications, certifications, and supervision criteria outlined in this policy, however, apply.

Group 2 Codes:

Group 3 Paragraph: The following HCPCS/CPT code is non-covered

Group 3 Codes:

ICD-10 Codes that Support Medical NecessityGroup 1 Paragraph: It is the provider’s responsibility to select codes carried out to the highest level ofspecificity and selected from the ICD-10-CM code book appropriate to the year in which the service is renderedfor the claim(s) submitted.

ICD-10-CM codes that support medical necessity of procedure codes 92265, 95860, 95861, 95863,95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95874, 95885, 95886, 95887, 95873,95907, 95908, 95909, 95910, 95911, 95912, 95913, 95933, 95999:

Group 1 Codes:



A35 Other tetanusB91 Sequelae of poliomyelitisC70.0 Malignant neoplasm of cerebral meningesC70.1 Malignant neoplasm of spinal meningesC70.9 Malignant neoplasm of meninges, unspecifiedC72.0 Malignant neoplasm of spinal cordC72.1 Malignant neoplasm of cauda equinaC72.20 Malignant neoplasm of unspecified olfactory nerveC72.21 Malignant neoplasm of right olfactory nerveC72.22 Malignant neoplasm of left olfactory nerveC72.30 Malignant neoplasm of unspecified optic nerveC72.31 Malignant neoplasm of right optic nerveC72.32 Malignant neoplasm of left optic nerveC72.40 Malignant neoplasm of unspecified acoustic nerveC72.41 Malignant neoplasm of right acoustic nerveC72.42 Malignant neoplasm of left acoustic nerveC72.50 Malignant neoplasm of unspecified cranial nerveC72.59 Malignant neoplasm of other cranial nervesC72.9 Malignant neoplasm of central nervous system, unspecifiedC79.31 Secondary malignant neoplasm of brainC79.32 Secondary malignant neoplasm of cerebral meningesC79.40 Secondary malignant neoplasm of unspecified part of nervous systemC79.49 Secondary malignant neoplasm of other parts of nervous systemC79.51 Secondary malignant neoplasm of boneC79.52 Secondary malignant neoplasm of bone marrowD32.1 Benign neoplasm of spinal meningesD33.3 Benign neoplasm of cranial nervesD33.4 Benign neoplasm of spinal cordD33.7 Benign neoplasm of other specified parts of central nervous systemE08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecifiedE08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathyE08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathyE08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathyE08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophyE08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complicationE08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy

E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabeticneuropathy, unspecified

E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabeticmononeuropathy

E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabeticpolyneuropathy

E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic(poly)neuropathy

E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabeticamyotrophy

E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabeticneurological complication

E09.610 Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathyE10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecifiedE10.41 Type 1 diabetes mellitus with diabetic mononeuropathyE10.42 Type 1 diabetes mellitus with diabetic polyneuropathyE10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathyE10.44 Type 1 diabetes mellitus with diabetic amyotrophyE10.49 Type 1 diabetes mellitus with other diabetic neurological complicationE10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathyE10.65 Type 1 diabetes mellitus with hyperglycemiaE11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified



E11.41 Type 2 diabetes mellitus with diabetic mononeuropathyE11.42 Type 2 diabetes mellitus with diabetic polyneuropathyE11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathyE11.44 Type 2 diabetes mellitus with diabetic amyotrophyE11.49 Type 2 diabetes mellitus with other diabetic neurological complicationE11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathyE11.65 Type 2 diabetes mellitus with hyperglycemiaE13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecifiedE13.41 Other specified diabetes mellitus with diabetic mononeuropathyE13.42 Other specified diabetes mellitus with diabetic polyneuropathyE13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathyE13.44 Other specified diabetes mellitus with diabetic amyotrophyE13.49 Other specified diabetes mellitus with other diabetic neurological complicationE13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathyE51.2 Wernicke's encephalopathyE51.8 Other manifestations of thiamine deficiencyE51.9 Thiamine deficiency, unspecifiedE56.0 Deficiency of vitamin EE56.8 Deficiency of other vitaminsE78.6 Lipoprotein deficiencyG04.1 Tropical spastic paraplegiaG11.0 Congenital nonprogressive ataxiaG11.1 Early-onset cerebellar ataxiaG11.2 Late-onset cerebellar ataxiaG11.3 Cerebellar ataxia with defective DNA repairG11.4 Hereditary spastic paraplegiaG11.8 Other hereditary ataxiasG11.9 Hereditary ataxia, unspecifiedG12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]G12.1 Other inherited spinal muscular atrophyG12.20 Motor neuron disease, unspecifiedG12.21 Amyotrophic lateral sclerosisG12.22 Progressive bulbar palsyG12.29 Other motor neuron diseaseG12.8 Other spinal muscular atrophies and related syndromesG12.9 Spinal muscular atrophy, unspecifiedG13.0 Paraneoplastic neuromyopathy and neuropathyG13.1 Other systemic atrophy primarily affecting central nervous system in neoplastic diseaseG14 Postpolio syndromeG20 Parkinson's diseaseG21.4 Vascular parkinsonismG24.01 Drug induced subacute dyskinesiaG24.02 Drug induced acute dystoniaG24.09 Other drug induced dystoniaG24.1 Genetic torsion dystoniaG24.2 Idiopathic nonfamilial dystoniaG24.3 Spasmodic torticollisG24.4 Idiopathic orofacial dystoniaG24.5 BlepharospasmG24.8 Other dystoniaG24.9 Dystonia, unspecifiedG25.3 MyoclonusG25.61 Drug induced ticsG25.69 Other tics of organic originG25.89 Other specified extrapyramidal and movement disordersG25.9 Extrapyramidal and movement disorder, unspecifiedG32.0 Subacute combined degeneration of spinal cord in diseases classified elsewhereG32.81 Cerebellar ataxia in diseases classified elsewherePrinted on 9/21/2015. Page 10 of 40


G35 Multiple sclerosisG36.0 Neuromyelitis optica [Devic]G36.1 Acute and subacute hemorrhagic leukoencephalitis [Hurst]G36.8 Other specified acute disseminated demyelinationG36.9 Acute disseminated demyelination, unspecifiedG37.0 Diffuse sclerosis of central nervous systemG37.1 Central demyelination of corpus callosumG37.2 Central pontine myelinolysisG37.3 Acute transverse myelitis in demyelinating disease of central nervous systemG37.4 Subacute necrotizing myelitis of central nervous systemG37.5 Concentric sclerosis [Balo] of central nervous systemG37.8 Other specified demyelinating diseases of central nervous systemG37.9 Demyelinating disease of central nervous system, unspecifiedG50.0 Trigeminal neuralgiaG50.1 Atypical facial painG50.8 Other disorders of trigeminal nerveG50.9 Disorder of trigeminal nerve, unspecifiedG51.0 Bell's palsyG51.1 Geniculate ganglionitisG51.2 Melkersson's syndromeG51.3 Clonic hemifacial spasmG51.4 Facial myokymiaG51.8 Other disorders of facial nerveG51.9 Disorder of facial nerve, unspecifiedG52.1 Disorders of glossopharyngeal nerveG52.2 Disorders of vagus nerveG52.3 Disorders of hypoglossal nerveG52.7 Disorders of multiple cranial nervesG52.8 Disorders of other specified cranial nervesG52.9 Cranial nerve disorder, unspecifiedG53 Cranial nerve disorders in diseases classified elsewhereG54.0 Brachial plexus disordersG54.1 Lumbosacral plexus disordersG54.2 Cervical root disorders, not elsewhere classifiedG54.3 Thoracic root disorders, not elsewhere classifiedG54.4 Lumbosacral root disorders, not elsewhere classifiedG54.5 Neuralgic amyotrophyG54.6 Phantom limb syndrome with painG54.7 Phantom limb syndrome without painG54.8 Other nerve root and plexus disordersG54.9 Nerve root and plexus disorder, unspecifiedG55 Nerve root and plexus compressions in diseases classified elsewhereG56.00 Carpal tunnel syndrome, unspecified upper limbG56.01 Carpal tunnel syndrome, right upper limbG56.02 Carpal tunnel syndrome, left upper limbG56.10 Other lesions of median nerve, unspecified upper limbG56.11 Other lesions of median nerve, right upper limbG56.12 Other lesions of median nerve, left upper limbG56.20 Lesion of ulnar nerve, unspecified upper limbG56.21 Lesion of ulnar nerve, right upper limbG56.22 Lesion of ulnar nerve, left upper limbG56.30 Lesion of radial nerve, unspecified upper limbG56.31 Lesion of radial nerve, right upper limbG56.32 Lesion of radial nerve, left upper limbG56.40 Causalgia of unspecified upper limbG56.41 Causalgia of right upper limbG56.42 Causalgia of left upper limb



G56.80 Other specified mononeuropathies of unspecified upper limbG56.81 Other specified mononeuropathies of right upper limbG56.82 Other specified mononeuropathies of left upper limbG56.90 Unspecified mononeuropathy of unspecified upper limbG56.91 Unspecified mononeuropathy of right upper limbG56.92 Unspecified mononeuropathy of left upper limbG57.00 Lesion of sciatic nerve, unspecified lower limbG57.01 Lesion of sciatic nerve, right lower limbG57.02 Lesion of sciatic nerve, left lower limbG57.10 Meralgia paresthetica, unspecified lower limbG57.11 Meralgia paresthetica, right lower limbG57.12 Meralgia paresthetica, left lower limbG57.20 Lesion of femoral nerve, unspecified lower limbG57.21 Lesion of femoral nerve, right lower limbG57.22 Lesion of femoral nerve, left lower limbG57.30 Lesion of lateral popliteal nerve, unspecified lower limbG57.31 Lesion of lateral popliteal nerve, right lower limbG57.32 Lesion of lateral popliteal nerve, left lower limbG57.40 Lesion of medial popliteal nerve, unspecified lower limbG57.41 Lesion of medial popliteal nerve, right lower limbG57.42 Lesion of medial popliteal nerve, left lower limbG57.50 Tarsal tunnel syndrome, unspecified lower limbG57.51 Tarsal tunnel syndrome, right lower limbG57.52 Tarsal tunnel syndrome, left lower limbG57.60 Lesion of plantar nerve, unspecified lower limbG57.61 Lesion of plantar nerve, right lower limbG57.62 Lesion of plantar nerve, left lower limbG57.70 Causalgia of unspecified lower limbG57.71 Causalgia of right lower limbG57.72 Causalgia of left lower limbG57.80 Other specified mononeuropathies of unspecified lower limbG57.81 Other specified mononeuropathies of right lower limbG57.82 Other specified mononeuropathies of left lower limbG57.90 Unspecified mononeuropathy of unspecified lower limbG57.91 Unspecified mononeuropathy of right lower limbG57.92 Unspecified mononeuropathy of left lower limbG58.0 Intercostal neuropathyG58.7 Mononeuritis multiplexG58.8 Other specified mononeuropathiesG58.9 Mononeuropathy, unspecifiedG59 Mononeuropathy in diseases classified elsewhereG60.0 Hereditary motor and sensory neuropathyG60.1 Refsum's diseaseG60.2 Neuropathy in association with hereditary ataxiaG60.3 Idiopathic progressive neuropathyG60.8 Other hereditary and idiopathic neuropathiesG60.9 Hereditary and idiopathic neuropathy, unspecifiedG61.0 Guillain-Barre syndromeG61.1 Serum neuropathyG61.81 Chronic inflammatory demyelinating polyneuritisG61.89 Other inflammatory polyneuropathiesG62.0 Drug-induced polyneuropathyG62.1 Alcoholic polyneuropathyG62.2 Polyneuropathy due to other toxic agentsG62.81 Critical illness polyneuropathyG62.82 Radiation-induced polyneuropathyG62.89 Other specified polyneuropathiesG63 Polyneuropathy in diseases classified elsewherePrinted on 9/21/2015. Page 12 of 40


G64 Other disorders of peripheral nervous systemG65.0 Sequelae of Guillain-Barre syndromeG65.1 Sequelae of other inflammatory polyneuropathyG65.2 Sequelae of toxic polyneuropathyG70.00 Myasthenia gravis without (acute) exacerbationG70.01 Myasthenia gravis with (acute) exacerbationG70.1 Toxic myoneural disordersG70.2 Congenital and developmental myastheniaG70.80 Lambert-Eaton syndrome, unspecifiedG70.81 Lambert-Eaton syndrome in disease classified elsewhereG70.89 Other specified myoneural disordersG70.9 Myoneural disorder, unspecifiedG71.0 Muscular dystrophyG71.11 Myotonic muscular dystrophyG71.12 Myotonia congenitaG71.13 Myotonic chondrodystrophyG71.14 Drug induced myotoniaG71.19 Other specified myotonic disordersG71.2 Congenital myopathiesG71.3 Mitochondrial myopathy, not elsewhere classifiedG71.8 Other primary disorders of musclesG71.9 Primary disorder of muscle, unspecifiedG72.0 Drug-induced myopathyG72.1 Alcoholic myopathyG72.2 Myopathy due to other toxic agentsG72.3 Periodic paralysisG72.41 Inclusion body myositis [IBM]G72.49 Other inflammatory and immune myopathies, not elsewhere classifiedG72.81 Critical illness myopathyG72.89 Other specified myopathiesG72.9 Myopathy, unspecifiedG73.1 Lambert-Eaton syndrome in neoplastic diseaseG73.3 Myasthenic syndromes in other diseases classified elsewhereG73.7 Myopathy in diseases classified elsewhereG80.0 Spastic quadriplegic cerebral palsyG80.1 Spastic diplegic cerebral palsyG80.2 Spastic hemiplegic cerebral palsyG80.3 Athetoid cerebral palsyG80.4 Ataxic cerebral palsyG80.8 Other cerebral palsyG80.9 Cerebral palsy, unspecifiedG81.00 Flaccid hemiplegia affecting unspecified sideG81.01 Flaccid hemiplegia affecting right dominant sideG81.02 Flaccid hemiplegia affecting left dominant sideG81.03 Flaccid hemiplegia affecting right nondominant sideG81.04 Flaccid hemiplegia affecting left nondominant sideG81.10 Spastic hemiplegia affecting unspecified sideG81.11 Spastic hemiplegia affecting right dominant sideG81.12 Spastic hemiplegia affecting left dominant sideG81.13 Spastic hemiplegia affecting right nondominant sideG81.14 Spastic hemiplegia affecting left nondominant sideG81.90 Hemiplegia, unspecified affecting unspecified sideG81.91 Hemiplegia, unspecified affecting right dominant sideG81.92 Hemiplegia, unspecified affecting left dominant sideG81.93 Hemiplegia, unspecified affecting right nondominant sideG81.94 Hemiplegia, unspecified affecting left nondominant sideG82.20 Paraplegia, unspecified



G82.21 Paraplegia, completeG82.22 Paraplegia, incompleteG82.50 Quadriplegia, unspecifiedG82.51 Quadriplegia, C1-C4 completeG82.52 Quadriplegia, C1-C4 incompleteG82.53 Quadriplegia, C5-C7 completeG82.54 Quadriplegia, C5-C7 incompleteG83.0 Diplegia of upper limbsG83.10 Monoplegia of lower limb affecting unspecified sideG83.11 Monoplegia of lower limb affecting right dominant sideG83.12 Monoplegia of lower limb affecting left dominant sideG83.13 Monoplegia of lower limb affecting right nondominant sideG83.14 Monoplegia of lower limb affecting left nondominant sideG83.20 Monoplegia of upper limb affecting unspecified sideG83.21 Monoplegia of upper limb affecting right dominant sideG83.22 Monoplegia of upper limb affecting left dominant sideG83.23 Monoplegia of upper limb affecting right nondominant sideG83.24 Monoplegia of upper limb affecting left nondominant sideG83.30 Monoplegia, unspecified affecting unspecified sideG83.31 Monoplegia, unspecified affecting right dominant sideG83.32 Monoplegia, unspecified affecting left dominant sideG83.33 Monoplegia, unspecified affecting right nondominant sideG83.34 Monoplegia, unspecified affecting left nondominant sideG83.4 Cauda equina syndromeG83.5 Locked-in stateG83.81 Brown-Sequard syndromeG83.82 Anterior cord syndromeG83.83 Posterior cord syndromeG83.84 Todd's paralysis (postepileptic)G83.89 Other specified paralytic syndromesG83.9 Paralytic syndrome, unspecifiedG90.01 Carotid sinus syncopeG90.09 Other idiopathic peripheral autonomic neuropathyG90.2 Horner's syndromeG90.4 Autonomic dysreflexiaG90.50 Complex regional pain syndrome I, unspecifiedG90.511 Complex regional pain syndrome I of right upper limbG90.512 Complex regional pain syndrome I of left upper limbG90.513 Complex regional pain syndrome I of upper limb, bilateralG90.519 Complex regional pain syndrome I of unspecified upper limbG90.521 Complex regional pain syndrome I of right lower limbG90.522 Complex regional pain syndrome I of left lower limbG90.523 Complex regional pain syndrome I of lower limb, bilateralG90.529 Complex regional pain syndrome I of unspecified lower limbG90.59 Complex regional pain syndrome I of other specified siteG90.8 Other disorders of autonomic nervous systemG90.9 Disorder of the autonomic nervous system, unspecifiedG93.3 Postviral fatigue syndromeG95.0 Syringomyelia and syringobulbiaG95.11 Acute infarction of spinal cord (embolic) (nonembolic)G95.19 Other vascular myelopathiesG95.20 Unspecified cord compressionG95.29 Other cord compressionG95.81 Conus medullaris syndromeG95.89 Other specified diseases of spinal cordG95.9 Disease of spinal cord, unspecifiedG99.0 Autonomic neuropathy in diseases classified elsewhereG99.2 Myelopathy in diseases classified elsewherePrinted on 9/21/2015. Page 14 of 40


H02.141 Spastic ectropion of right upper eyelidH02.142 Spastic ectropion of right lower eyelidH02.143 Spastic ectropion of right eye, unspecified eyelidH02.144 Spastic ectropion of left upper eyelidH02.145 Spastic ectropion of left lower eyelidH02.146 Spastic ectropion of left eye, unspecified eyelidH02.149 Spastic ectropion of unspecified eye, unspecified eyelidH49.00 Third [oculomotor] nerve palsy, unspecified eyeH49.01 Third [oculomotor] nerve palsy, right eyeH49.02 Third [oculomotor] nerve palsy, left eyeH49.03 Third [oculomotor] nerve palsy, bilateralH49.10 Fourth [trochlear] nerve palsy, unspecified eyeH49.11 Fourth [trochlear] nerve palsy, right eyeH49.12 Fourth [trochlear] nerve palsy, left eyeH49.13 Fourth [trochlear] nerve palsy, bilateralH49.20 Sixth [abducent] nerve palsy, unspecified eyeH49.21 Sixth [abducent] nerve palsy, right eyeH49.22 Sixth [abducent] nerve palsy, left eyeH49.23 Sixth [abducent] nerve palsy, bilateralH49.30 Total (external) ophthalmoplegia, unspecified eyeH49.31 Total (external) ophthalmoplegia, right eyeH49.32 Total (external) ophthalmoplegia, left eyeH49.33 Total (external) ophthalmoplegia, bilateralH49.40 Progressive external ophthalmoplegia, unspecified eyeH49.41 Progressive external ophthalmoplegia, right eyeH49.42 Progressive external ophthalmoplegia, left eyeH49.43 Progressive external ophthalmoplegia, bilateralH49.881 Other paralytic strabismus, right eyeH49.882 Other paralytic strabismus, left eyeH49.883 Other paralytic strabismus, bilateralH49.889 Other paralytic strabismus, unspecified eyeH49.9 Unspecified paralytic strabismusH50.00 Unspecified esotropiaH50.011 Monocular esotropia, right eyeH50.012 Monocular esotropia, left eyeH50.021 Monocular esotropia with A pattern, right eyeH50.022 Monocular esotropia with A pattern, left eyeH50.031 Monocular esotropia with V pattern, right eyeH50.032 Monocular esotropia with V pattern, left eyeH50.041 Monocular esotropia with other noncomitancies, right eyeH50.042 Monocular esotropia with other noncomitancies, left eyeH50.05 Alternating esotropiaH50.06 Alternating esotropia with A patternH50.07 Alternating esotropia with V patternH50.08 Alternating esotropia with other noncomitanciesH50.10 Unspecified exotropiaH50.111 Monocular exotropia, right eyeH50.112 Monocular exotropia, left eyeH50.121 Monocular exotropia with A pattern, right eyeH50.122 Monocular exotropia with A pattern, left eyeH50.131 Monocular exotropia with V pattern, right eyeH50.132 Monocular exotropia with V pattern, left eyeH50.141 Monocular exotropia with other noncomitancies, right eyeH50.142 Monocular exotropia with other noncomitancies, left eyeH50.15 Alternating exotropiaH50.16 Alternating exotropia with A patternH50.17 Alternating exotropia with V pattern



H50.18 Alternating exotropia with other noncomitanciesH50.21 Vertical strabismus, right eyeH50.22 Vertical strabismus, left eyeH50.30 Unspecified intermittent heterotropiaH50.311 Intermittent monocular esotropia, right eyeH50.312 Intermittent monocular esotropia, left eyeH50.32 Intermittent alternating esotropiaH50.331 Intermittent monocular exotropia, right eyeH50.332 Intermittent monocular exotropia, left eyeH50.34 Intermittent alternating exotropiaH50.40 Unspecified heterotropiaH50.411 Cyclotropia, right eyeH50.412 Cyclotropia, left eyeH50.42 Monofixation syndromeH50.43 Accommodative component in esotropiaH50.50 Unspecified heterophoriaH50.51 EsophoriaH50.52 ExophoriaH50.53 Vertical heterophoriaH50.54 CyclophoriaH50.55 Alternating heterophoriaH50.60 Mechanical strabismus, unspecifiedH50.611 Brown's sheath syndrome, right eyeH50.612 Brown's sheath syndrome, left eyeH50.69 Other mechanical strabismusH50.811 Duane's syndrome, right eyeH50.812 Duane's syndrome, left eyeH50.89 Other specified strabismusH50.9 Unspecified strabismusH51.0 Palsy (spasm) of conjugate gazeH51.11 Convergence insufficiencyH51.12 Convergence excessH51.20 Internuclear ophthalmoplegia, unspecified eyeH51.21 Internuclear ophthalmoplegia, right eyeH51.22 Internuclear ophthalmoplegia, left eyeH51.23 Internuclear ophthalmoplegia, bilateralH51.8 Other specified disorders of binocular movementH51.9 Unspecified disorder of binocular movement

I69.033 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right non-dominant side

I69.034 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side

I69.041 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting rightdominant side

I69.042 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left dominantside

I69.043 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right non-dominant side

I69.044 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side

I69.133 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right non-dominant side

I69.134 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side

I69.141 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right dominantside

I69.142 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left dominantside

I69.143Printed on 9/21/2015. Page 16 of 40


Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right non-dominant side

I69.144 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side

I69.233 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side

I69.234 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side

I69.241 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting rightdominant side

I69.242 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting leftdominant side

I69.243 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side

I69.244 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side

I69.333 Monoplegia of upper limb following cerebral infarction affecting right non-dominant sideI69.334 Monoplegia of upper limb following cerebral infarction affecting left non-dominant sideI69.341 Monoplegia of lower limb following cerebral infarction affecting right dominant sideI69.342 Monoplegia of lower limb following cerebral infarction affecting left dominant sideI69.343 Monoplegia of lower limb following cerebral infarction affecting right non-dominant sideI69.344 Monoplegia of lower limb following cerebral infarction affecting left non-dominant sideI69.833 Monoplegia of upper limb following other cerebrovascular disease affecting right non-dominant sideI69.834 Monoplegia of upper limb following other cerebrovascular disease affecting left non-dominant sideI69.841 Monoplegia of lower limb following other cerebrovascular disease affecting right dominant sideI69.842 Monoplegia of lower limb following other cerebrovascular disease affecting left dominant sideI69.843 Monoplegia of lower limb following other cerebrovascular disease affecting right non-dominant sideI69.844 Monoplegia of lower limb following other cerebrovascular disease affecting left non-dominant side

I69.933 Monoplegia of upper limb following unspecified cerebrovascular disease affecting right non-dominant side

I69.934 Monoplegia of upper limb following unspecified cerebrovascular disease affecting left non-dominantside

I69.941 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right dominantside

I69.942 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left dominant side

I69.943 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right non-dominant side

I69.944 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left non-dominantside

I95.1 Orthostatic hypotensionJ38.00 Paralysis of vocal cords and larynx, unspecifiedJ38.01 Paralysis of vocal cords and larynx, unilateralJ38.02 Paralysis of vocal cords and larynx, bilateralJ38.5 Laryngeal spasmJ38.7 Other diseases of larynxK22.0 Achalasia of cardiaM05.411 Rheumatoid myopathy with rheumatoid arthritis of right shoulderM05.412 Rheumatoid myopathy with rheumatoid arthritis of left shoulderM05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbowM05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbowM05.431 Rheumatoid myopathy with rheumatoid arthritis of right wristM05.432 Rheumatoid myopathy with rheumatoid arthritis of left wristM05.441 Rheumatoid myopathy with rheumatoid arthritis of right handM05.442 Rheumatoid myopathy with rheumatoid arthritis of left handM05.451 Rheumatoid myopathy with rheumatoid arthritis of right hipM05.452 Rheumatoid myopathy with rheumatoid arthritis of left hipM05.461 Rheumatoid myopathy with rheumatoid arthritis of right kneeM05.462 Rheumatoid myopathy with rheumatoid arthritis of left kneeM05.471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot



M05.472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and footM05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sitesM05.511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulderM05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulderM05.521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbowM05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbowM05.531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wristM05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wristM05.541 Rheumatoid polyneuropathy with rheumatoid arthritis of right handM05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of left handM05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hipM05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hipM05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right kneeM05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left kneeM05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and footM05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and footM05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sitesM21.071 Valgus deformity, not elsewhere classified, right ankleM21.072 Valgus deformity, not elsewhere classified, left ankleM21.079 Valgus deformity, not elsewhere classified, unspecified ankleM21.171 Varus deformity, not elsewhere classified, right ankleM21.172 Varus deformity, not elsewhere classified, left ankleM21.179 Varus deformity, not elsewhere classified, unspecified ankleM21.331 Wrist drop, right wristM21.332 Wrist drop, left wristM21.339 Wrist drop, unspecified wristM21.371 Foot drop, right footM21.372 Foot drop, left footM21.379 Foot drop, unspecified footM21.511 Acquired clawhand, right handM21.512 Acquired clawhand, left handM21.519 Acquired clawhand, unspecified handM21.531 Acquired clawfoot, right footM21.532 Acquired clawfoot, left footM21.539 Acquired clawfoot, unspecified footM21.541 Acquired clubfoot, right footM21.542 Acquired clubfoot, left footM21.549 Acquired clubfoot, unspecified footM21.6X1 Other acquired deformities of right footM21.6X2 Other acquired deformities of left footM21.6X9 Other acquired deformities of unspecified footM21.831 Other specified acquired deformities of right forearmM21.832 Other specified acquired deformities of left forearmM21.839 Other specified acquired deformities of unspecified forearmM21.961 Unspecified acquired deformity of right lower legM21.962 Unspecified acquired deformity of left lower legM21.969 Unspecified acquired deformity of unspecified lower legM25.78 Osteophyte, vertebraeM33.00 Juvenile dermatopolymyositis, organ involvement unspecifiedM33.01 Juvenile dermatopolymyositis with respiratory involvementM33.02 Juvenile dermatopolymyositis with myopathyM33.09 Juvenile dermatopolymyositis with other organ involvementM33.10 Other dermatopolymyositis, organ involvement unspecifiedM33.11 Other dermatopolymyositis with respiratory involvementM33.12 Other dermatopolymyositis with myopathyM33.19 Other dermatopolymyositis with other organ involvementM33.20 Polymyositis, organ involvement unspecifiedM33.21 Polymyositis with respiratory involvementPrinted on 9/21/2015. Page 18 of 40


M33.22 Polymyositis with myopathyM33.29 Polymyositis with other organ involvementM33.90 Dermatopolymyositis, unspecified, organ involvement unspecifiedM33.91 Dermatopolymyositis, unspecified with respiratory involvementM33.92 Dermatopolymyositis, unspecified with myopathyM33.99 Dermatopolymyositis, unspecified with other organ involvementM35.3 Polymyalgia rheumaticaM35.4 Diffuse (eosinophilic) fasciitisM35.8 Other specified systemic involvement of connective tissueM36.0 Dermato(poly)myositis in neoplastic diseaseM43.00 Spondylolysis, site unspecifiedM43.01 Spondylolysis, occipito-atlanto-axial regionM43.02 Spondylolysis, cervical regionM43.03 Spondylolysis, cervicothoracic regionM43.04 Spondylolysis, thoracic regionM43.05 Spondylolysis, thoracolumbar regionM43.06 Spondylolysis, lumbar regionM43.07 Spondylolysis, lumbosacral regionM43.08 Spondylolysis, sacral and sacrococcygeal regionM43.09 Spondylolysis, multiple sites in spineM43.10 Spondylolisthesis, site unspecifiedM43.11 Spondylolisthesis, occipito-atlanto-axial regionM43.12 Spondylolisthesis, cervical regionM43.13 Spondylolisthesis, cervicothoracic regionM43.14 Spondylolisthesis, thoracic regionM43.15 Spondylolisthesis, thoracolumbar regionM43.16 Spondylolisthesis, lumbar regionM43.17 Spondylolisthesis, lumbosacral regionM43.18 Spondylolisthesis, sacral and sacrococcygeal regionM43.19 Spondylolisthesis, multiple sites in spineM43.6 TorticollisM46.41 Discitis, unspecified, occipito-atlanto-axial regionM46.42 Discitis, unspecified, cervical regionM46.43 Discitis, unspecified, cervicothoracic regionM46.44 Discitis, unspecified, thoracic regionM46.45 Discitis, unspecified, thoracolumbar regionM46.46 Discitis, unspecified, lumbar regionM46.47 Discitis, unspecified, lumbosacral regionM47.011 Anterior spinal artery compression syndromes, occipito-atlanto-axial regionM47.012 Anterior spinal artery compression syndromes, cervical regionM47.013 Anterior spinal artery compression syndromes, cervicothoracic regionM47.014 Anterior spinal artery compression syndromes, thoracic regionM47.015 Anterior spinal artery compression syndromes, thoracolumbar regionM47.016 Anterior spinal artery compression syndromes, lumbar regionM47.019 Anterior spinal artery compression syndromes, site unspecifiedM47.021 Vertebral artery compression syndromes, occipito-atlanto-axial regionM47.022 Vertebral artery compression syndromes, cervical regionM47.029 Vertebral artery compression syndromes, site unspecifiedM47.10 Other spondylosis with myelopathy, site unspecifiedM47.11 Other spondylosis with myelopathy, occipito-atlanto-axial regionM47.12 Other spondylosis with myelopathy, cervical regionM47.13 Other spondylosis with myelopathy, cervicothoracic regionM47.14 Other spondylosis with myelopathy, thoracic regionM47.15 Other spondylosis with myelopathy, thoracolumbar regionM47.16 Other spondylosis with myelopathy, lumbar regionM47.20 Other spondylosis with radiculopathy, site unspecifiedM47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region



M47.22 Other spondylosis with radiculopathy, cervical regionM47.23 Other spondylosis with radiculopathy, cervicothoracic regionM47.24 Other spondylosis with radiculopathy, thoracic regionM47.25 Other spondylosis with radiculopathy, thoracolumbar regionM47.26 Other spondylosis with radiculopathy, lumbar regionM47.27 Other spondylosis with radiculopathy, lumbosacral regionM47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal regionM47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial regionM47.812 Spondylosis without myelopathy or radiculopathy, cervical regionM47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic regionM47.814 Spondylosis without myelopathy or radiculopathy, thoracic regionM47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar regionM47.816 Spondylosis without myelopathy or radiculopathy, lumbar regionM47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral regionM47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal regionM47.819 Spondylosis without myelopathy or radiculopathy, site unspecifiedM47.891 Other spondylosis, occipito-atlanto-axial regionM47.892 Other spondylosis, cervical regionM47.893 Other spondylosis, cervicothoracic regionM47.894 Other spondylosis, thoracic regionM47.895 Other spondylosis, thoracolumbar regionM47.896 Other spondylosis, lumbar regionM47.897 Other spondylosis, lumbosacral regionM47.898 Other spondylosis, sacral and sacrococcygeal regionM47.899 Other spondylosis, site unspecifiedM47.9 Spondylosis, unspecifiedM48.00 Spinal stenosis, site unspecifiedM48.01 Spinal stenosis, occipito-atlanto-axial regionM48.02 Spinal stenosis, cervical regionM48.03 Spinal stenosis, cervicothoracic regionM48.04 Spinal stenosis, thoracic regionM48.05 Spinal stenosis, thoracolumbar regionM48.06 Spinal stenosis, lumbar regionM48.07 Spinal stenosis, lumbosacral regionM48.08 Spinal stenosis, sacral and sacrococcygeal regionM48.10 Ankylosing hyperostosis [Forestier], site unspecifiedM48.11 Ankylosing hyperostosis [Forestier], occipito-atlanto-axial regionM48.12 Ankylosing hyperostosis [Forestier], cervical regionM48.13 Ankylosing hyperostosis [Forestier], cervicothoracic regionM48.14 Ankylosing hyperostosis [Forestier], thoracic regionM48.15 Ankylosing hyperostosis [Forestier], thoracolumbar regionM48.16 Ankylosing hyperostosis [Forestier], lumbar regionM48.17 Ankylosing hyperostosis [Forestier], lumbosacral regionM48.18 Ankylosing hyperostosis [Forestier], sacral and sacrococcygeal regionM48.19 Ankylosing hyperostosis [Forestier], multiple sites in spineM48.20 Kissing spine, site unspecifiedM48.21 Kissing spine, occipito-atlanto-axial regionM48.22 Kissing spine, cervical regionM48.23 Kissing spine, cervicothoracic regionM48.24 Kissing spine, thoracic regionM48.25 Kissing spine, thoracolumbar regionM48.26 Kissing spine, lumbar regionM48.27 Kissing spine, lumbosacral regionM48.30 Traumatic spondylopathy, site unspecifiedM48.31 Traumatic spondylopathy, occipito-atlanto-axial regionM48.32 Traumatic spondylopathy, cervical regionM48.33 Traumatic spondylopathy, cervicothoracic regionM48.34 Traumatic spondylopathy, thoracic regionPrinted on 9/21/2015. Page 20 of 40


M48.35 Traumatic spondylopathy, thoracolumbar regionM48.36 Traumatic spondylopathy, lumbar regionM48.37 Traumatic spondylopathy, lumbosacral regionM48.38 Traumatic spondylopathy, sacral and sacrococcygeal regionM48.9 Spondylopathy, unspecifiedM50.00 Cervical disc disorder with myelopathy, unspecified cervical regionM50.01 Cervical disc disorder with myelopathy, high cervical regionM50.02 Cervical disc disorder with myelopathy, mid-cervical regionM50.03 Cervical disc disorder with myelopathy, cervicothoracic regionM50.10 Cervical disc disorder with radiculopathy, unspecified cervical regionM50.11 Cervical disc disorder with radiculopathy, high cervical regionM50.12 Cervical disc disorder with radiculopathy, mid-cervical regionM50.13 Cervical disc disorder with radiculopathy, cervicothoracic regionM50.20 Other cervical disc displacement, unspecified cervical regionM50.21 Other cervical disc displacement, high cervical regionM50.22 Other cervical disc displacement, mid-cervical regionM50.23 Other cervical disc displacement, cervicothoracic regionM50.30 Other cervical disc degeneration, unspecified cervical regionM50.31 Other cervical disc degeneration, high cervical regionM50.32 Other cervical disc degeneration, mid-cervical regionM50.33 Other cervical disc degeneration, cervicothoracic regionM50.80 Other cervical disc disorders, unspecified cervical regionM50.81 Other cervical disc disorders, high cervical regionM50.82 Other cervical disc disorders, mid-cervical regionM50.83 Other cervical disc disorders, cervicothoracic regionM50.90 Cervical disc disorder, unspecified, unspecified cervical regionM50.91 Cervical disc disorder, unspecified, high cervical regionM50.92 Cervical disc disorder, unspecified, mid-cervical regionM50.93 Cervical disc disorder, unspecified, cervicothoracic regionM51.04 Intervertebral disc disorders with myelopathy, thoracic regionM51.05 Intervertebral disc disorders with myelopathy, thoracolumbar regionM51.06 Intervertebral disc disorders with myelopathy, lumbar regionM51.14 Intervertebral disc disorders with radiculopathy, thoracic regionM51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar regionM51.16 Intervertebral disc disorders with radiculopathy, lumbar regionM51.17 Intervertebral disc disorders with radiculopathy, lumbosacral regionM51.24 Other intervertebral disc displacement, thoracic regionM51.25 Other intervertebral disc displacement, thoracolumbar regionM51.26 Other intervertebral disc displacement, lumbar regionM51.27 Other intervertebral disc displacement, lumbosacral regionM51.34 Other intervertebral disc degeneration, thoracic regionM51.35 Other intervertebral disc degeneration, thoracolumbar regionM51.36 Other intervertebral disc degeneration, lumbar regionM51.37 Other intervertebral disc degeneration, lumbosacral regionM51.44 Schmorl's nodes, thoracic regionM51.45 Schmorl's nodes, thoracolumbar regionM51.46 Schmorl's nodes, lumbar regionM51.47 Schmorl's nodes, lumbosacral regionM51.84 Other intervertebral disc disorders, thoracic regionM51.85 Other intervertebral disc disorders, thoracolumbar regionM51.86 Other intervertebral disc disorders, lumbar regionM51.87 Other intervertebral disc disorders, lumbosacral regionM51.9 Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorderM53.0 Cervicocranial syndromeM53.1 Cervicobrachial syndromeM53.82 Other specified dorsopathies, cervical regionM54.10 Radiculopathy, site unspecified



M54.11 Radiculopathy, occipito-atlanto-axial regionM54.12 Radiculopathy, cervical regionM54.13 Radiculopathy, cervicothoracic regionM54.14 Radiculopathy, thoracic regionM54.15 Radiculopathy, thoracolumbar regionM54.16 Radiculopathy, lumbar regionM54.17 Radiculopathy, lumbosacral regionM54.18 Radiculopathy, sacral and sacrococcygeal regionM54.2 CervicalgiaM54.30 Sciatica, unspecified sideM54.31 Sciatica, right sideM54.32 Sciatica, left sideM54.40 Lumbago with sciatica, unspecified sideM54.41 Lumbago with sciatica, right sideM54.42 Lumbago with sciatica, left sideM54.5 Low back painM54.6 Pain in thoracic spineM54.89 Other dorsalgiaM54.9 Dorsalgia, unspecifiedM60.000 Infective myositis, unspecified right armM60.001 Infective myositis, unspecified left armM60.002 Infective myositis, unspecified armM60.003 Infective myositis, unspecified right legM60.004 Infective myositis, unspecified left legM60.005 Infective myositis, unspecified legM60.009 Infective myositis, unspecified siteM60.011 Infective myositis, right shoulderM60.012 Infective myositis, left shoulderM60.019 Infective myositis, unspecified shoulderM60.021 Infective myositis, right upper armM60.022 Infective myositis, left upper armM60.029 Infective myositis, unspecified upper armM60.031 Infective myositis, right forearmM60.032 Infective myositis, left forearmM60.039 Infective myositis, unspecified forearmM60.041 Infective myositis, right handM60.042 Infective myositis, left handM60.043 Infective myositis, unspecified handM60.044 Infective myositis, right finger(s)M60.045 Infective myositis, left finger(s)M60.046 Infective myositis, unspecified finger(s)M60.051 Infective myositis, right thighM60.052 Infective myositis, left thighM60.059 Infective myositis, unspecified thighM60.061 Infective myositis, right lower legM60.062 Infective myositis, left lower legM60.069 Infective myositis, unspecified lower legM60.070 Infective myositis, right ankleM60.071 Infective myositis, left ankleM60.072 Infective myositis, unspecified ankleM60.073 Infective myositis, right footM60.074 Infective myositis, left footM60.075 Infective myositis, unspecified footM60.076 Infective myositis, right toe(s)M60.077 Infective myositis, left toe(s)M60.078 Infective myositis, unspecified toe(s)M60.08 Infective myositis, other siteM60.09 Infective myositis, multiple sitesPrinted on 9/21/2015. Page 22 of 40


M60.80 Other myositis, unspecified siteM60.811 Other myositis, right shoulderM60.812 Other myositis, left shoulderM60.819 Other myositis, unspecified shoulderM60.821 Other myositis, right upper armM60.822 Other myositis, left upper armM60.829 Other myositis, unspecified upper armM60.831 Other myositis, right forearmM60.832 Other myositis, left forearmM60.839 Other myositis, unspecified forearmM60.841 Other myositis, right handM60.842 Other myositis, left handM60.849 Other myositis, unspecified handM60.851 Other myositis, right thighM60.852 Other myositis, left thighM60.859 Other myositis, unspecified thighM60.861 Other myositis, right lower legM60.862 Other myositis, left lower legM60.869 Other myositis, unspecified lower legM60.871 Other myositis, right ankle and footM60.872 Other myositis, left ankle and footM60.879 Other myositis, unspecified ankle and footM60.88 Other myositis, other siteM60.89 Other myositis, multiple sitesM60.9 Myositis, unspecifiedM62.20 Nontraumatic ischemic infarction of muscle, unspecified siteM62.211 Nontraumatic ischemic infarction of muscle, right shoulderM62.212 Nontraumatic ischemic infarction of muscle, left shoulderM62.219 Nontraumatic ischemic infarction of muscle, unspecified shoulderM62.221 Nontraumatic ischemic infarction of muscle, right upper armM62.222 Nontraumatic ischemic infarction of muscle, left upper armM62.229 Nontraumatic ischemic infarction of muscle, unspecified upper armM62.231 Nontraumatic ischemic infarction of muscle, right forearmM62.232 Nontraumatic ischemic infarction of muscle, left forearmM62.239 Nontraumatic ischemic infarction of muscle, unspecified forearmM62.241 Nontraumatic ischemic infarction of muscle, right handM62.242 Nontraumatic ischemic infarction of muscle, left handM62.249 Nontraumatic ischemic infarction of muscle, unspecified handM62.251 Nontraumatic ischemic infarction of muscle, right thighM62.252 Nontraumatic ischemic infarction of muscle, left thighM62.259 Nontraumatic ischemic infarction of muscle, unspecified thighM62.261 Nontraumatic ischemic infarction of muscle, right lower legM62.262 Nontraumatic ischemic infarction of muscle, left lower legM62.269 Nontraumatic ischemic infarction of muscle, unspecified lower legM62.271 Nontraumatic ischemic infarction of muscle, right ankle and footM62.272 Nontraumatic ischemic infarction of muscle, left ankle and footM62.279 Nontraumatic ischemic infarction of muscle, unspecified ankle and footM62.28 Nontraumatic ischemic infarction of muscle, other siteM62.40 Contracture of muscle, unspecified siteM62.411 Contracture of muscle, right shoulderM62.412 Contracture of muscle, left shoulderM62.419 Contracture of muscle, unspecified shoulderM62.421 Contracture of muscle, right upper armM62.422 Contracture of muscle, left upper armM62.429 Contracture of muscle, unspecified upper armM62.431 Contracture of muscle, right forearmM62.432 Contracture of muscle, left forearm



M62.439 Contracture of muscle, unspecified forearmM62.441 Contracture of muscle, right handM62.442 Contracture of muscle, left handM62.449 Contracture of muscle, unspecified handM62.451 Contracture of muscle, right thighM62.452 Contracture of muscle, left thighM62.459 Contracture of muscle, unspecified thighM62.461 Contracture of muscle, right lower legM62.462 Contracture of muscle, left lower legM62.469 Contracture of muscle, unspecified lower legM62.471 Contracture of muscle, right ankle and footM62.472 Contracture of muscle, left ankle and footM62.479 Contracture of muscle, unspecified ankle and footM62.48 Contracture of muscle, other siteM62.49 Contracture of muscle, multiple sitesM62.50 Muscle wasting and atrophy, not elsewhere classified, unspecified siteM62.511 Muscle wasting and atrophy, not elsewhere classified, right shoulderM62.512 Muscle wasting and atrophy, not elsewhere classified, left shoulderM62.519 Muscle wasting and atrophy, not elsewhere classified, unspecified shoulderM62.521 Muscle wasting and atrophy, not elsewhere classified, right upper armM62.522 Muscle wasting and atrophy, not elsewhere classified, left upper armM62.529 Muscle wasting and atrophy, not elsewhere classified, unspecified upper armM62.531 Muscle wasting and atrophy, not elsewhere classified, right forearmM62.532 Muscle wasting and atrophy, not elsewhere classified, left forearmM62.539 Muscle wasting and atrophy, not elsewhere classified, unspecified forearmM62.541 Muscle wasting and atrophy, not elsewhere classified, right handM62.542 Muscle wasting and atrophy, not elsewhere classified, left handM62.549 Muscle wasting and atrophy, not elsewhere classified, unspecified handM62.551 Muscle wasting and atrophy, not elsewhere classified, right thighM62.552 Muscle wasting and atrophy, not elsewhere classified, left thighM62.559 Muscle wasting and atrophy, not elsewhere classified, unspecified thighM62.561 Muscle wasting and atrophy, not elsewhere classified, right lower legM62.562 Muscle wasting and atrophy, not elsewhere classified, left lower legM62.569 Muscle wasting and atrophy, not elsewhere classified, unspecified lower legM62.571 Muscle wasting and atrophy, not elsewhere classified, right ankle and footM62.572 Muscle wasting and atrophy, not elsewhere classified, left ankle and footM62.579 Muscle wasting and atrophy, not elsewhere classified, unspecified ankle and footM62.58 Muscle wasting and atrophy, not elsewhere classified, other siteM62.59 Muscle wasting and atrophy, not elsewhere classified, multiple sitesM62.81 Muscle weakness (generalized)M62.82 RhabdomyolysisM62.831 Muscle spasm of calfM62.838 Other muscle spasmM62.89 Other specified disorders of muscleM62.9 Disorder of muscle, unspecifiedM63.80 Disorders of muscle in diseases classified elsewhere, unspecified siteM63.811 Disorders of muscle in diseases classified elsewhere, right shoulderM63.812 Disorders of muscle in diseases classified elsewhere, left shoulderM63.819 Disorders of muscle in diseases classified elsewhere, unspecified shoulderM63.821 Disorders of muscle in diseases classified elsewhere, right upper armM63.822 Disorders of muscle in diseases classified elsewhere, left upper armM63.829 Disorders of muscle in diseases classified elsewhere, unspecified upper armM63.831 Disorders of muscle in diseases classified elsewhere, right forearmM63.832 Disorders of muscle in diseases classified elsewhere, left forearmM63.839 Disorders of muscle in diseases classified elsewhere, unspecified forearmM63.841 Disorders of muscle in diseases classified elsewhere, right handM63.842 Disorders of muscle in diseases classified elsewhere, left handM63.849 Disorders of muscle in diseases classified elsewhere, unspecified handPrinted on 9/21/2015. Page 24 of 40


M63.851 Disorders of muscle in diseases classified elsewhere, right thighM63.852 Disorders of muscle in diseases classified elsewhere, left thighM63.859 Disorders of muscle in diseases classified elsewhere, unspecified thighM63.861 Disorders of muscle in diseases classified elsewhere, right lower legM63.862 Disorders of muscle in diseases classified elsewhere, left lower legM63.869 Disorders of muscle in diseases classified elsewhere, unspecified lower legM63.871 Disorders of muscle in diseases classified elsewhere, right ankle and footM63.872 Disorders of muscle in diseases classified elsewhere, left ankle and footM63.879 Disorders of muscle in diseases classified elsewhere, unspecified ankle and footM63.88 Disorders of muscle in diseases classified elsewhere, other siteM63.89 Disorders of muscle in diseases classified elsewhere, multiple sitesM72.8 Other fibroblastic disordersM79.1 MyalgiaM79.2 Neuralgia and neuritis, unspecifiedM79.601 Pain in right armM79.602 Pain in left armM79.603 Pain in arm, unspecifiedM79.604 Pain in right legM79.605 Pain in left legM79.606 Pain in leg, unspecifiedM79.609 Pain in unspecified limbM79.621 Pain in right upper armM79.622 Pain in left upper armM79.629 Pain in unspecified upper armM79.631 Pain in right forearmM79.632 Pain in left forearmM79.639 Pain in unspecified forearmM79.641 Pain in right handM79.642 Pain in left handM79.643 Pain in unspecified handM79.644 Pain in right finger(s)M79.645 Pain in left finger(s)M79.646 Pain in unspecified finger(s)M79.651 Pain in right thighM79.652 Pain in left thighM79.659 Pain in unspecified thighM79.661 Pain in right lower legM79.662 Pain in left lower legM79.669 Pain in unspecified lower legM79.671 Pain in right footM79.672 Pain in left footM79.673 Pain in unspecified footM79.674 Pain in right toe(s)M79.675 Pain in left toe(s)M79.676 Pain in unspecified toe(s)M79.7 FibromyalgiaM96.1 Postlaminectomy syndrome, not elsewhere classifiedM99.20 Subluxation stenosis of neural canal of head regionM99.21 Subluxation stenosis of neural canal of cervical regionM99.22 Subluxation stenosis of neural canal of thoracic regionM99.23 Subluxation stenosis of neural canal of lumbar regionM99.24 Subluxation stenosis of neural canal of sacral regionM99.25 Subluxation stenosis of neural canal of pelvic regionM99.26 Subluxation stenosis of neural canal of lower extremityM99.27 Subluxation stenosis of neural canal of upper extremityM99.28 Subluxation stenosis of neural canal of rib cageM99.29 Subluxation stenosis of neural canal of abdomen and other regions



M99.30 Osseous stenosis of neural canal of head regionM99.31 Osseous stenosis of neural canal of cervical regionM99.32 Osseous stenosis of neural canal of thoracic regionM99.33 Osseous stenosis of neural canal of lumbar regionM99.34 Osseous stenosis of neural canal of sacral regionM99.35 Osseous stenosis of neural canal of pelvic regionM99.36 Osseous stenosis of neural canal of lower extremityM99.37 Osseous stenosis of neural canal of upper extremityM99.38 Osseous stenosis of neural canal of rib cageM99.39 Osseous stenosis of neural canal of abdomen and other regionsM99.40 Connective tissue stenosis of neural canal of head regionM99.41 Connective tissue stenosis of neural canal of cervical regionM99.42 Connective tissue stenosis of neural canal of thoracic regionM99.43 Connective tissue stenosis of neural canal of lumbar regionM99.44 Connective tissue stenosis of neural canal of sacral regionM99.45 Connective tissue stenosis of neural canal of pelvic regionM99.46 Connective tissue stenosis of neural canal of lower extremityM99.47 Connective tissue stenosis of neural canal of upper extremityM99.48 Connective tissue stenosis of neural canal of rib cageM99.49 Connective tissue stenosis of neural canal of abdomen and other regionsM99.50 Intervertebral disc stenosis of neural canal of head regionM99.51 Intervertebral disc stenosis of neural canal of cervical regionM99.52 Intervertebral disc stenosis of neural canal of thoracic regionM99.53 Intervertebral disc stenosis of neural canal of lumbar regionM99.54 Intervertebral disc stenosis of neural canal of sacral regionM99.55 Intervertebral disc stenosis of neural canal of pelvic regionM99.56 Intervertebral disc stenosis of neural canal of lower extremityM99.57 Intervertebral disc stenosis of neural canal of upper extremityM99.58 Intervertebral disc stenosis of neural canal of rib cageM99.59 Intervertebral disc stenosis of neural canal of abdomen and other regionsM99.60 Osseous and subluxation stenosis of intervertebral foramina of head regionM99.61 Osseous and subluxation stenosis of intervertebral foramina of cervical regionM99.62 Osseous and subluxation stenosis of intervertebral foramina of thoracic regionM99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar regionM99.64 Osseous and subluxation stenosis of intervertebral foramina of sacral regionM99.65 Osseous and subluxation stenosis of intervertebral foramina of pelvic regionM99.66 Osseous and subluxation stenosis of intervertebral foramina of lower extremityM99.67 Osseous and subluxation stenosis of intervertebral foramina of upper extremityM99.68 Osseous and subluxation stenosis of intervertebral foramina of rib cageM99.69 Osseous and subluxation stenosis of intervertebral foramina of abdomen and other regionsM99.70 Connective tissue and disc stenosis of intervertebral foramina of head regionM99.71 Connective tissue and disc stenosis of intervertebral foramina of cervical regionM99.72 Connective tissue and disc stenosis of intervertebral foramina of thoracic regionM99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar regionM99.74 Connective tissue and disc stenosis of intervertebral foramina of sacral regionM99.75 Connective tissue and disc stenosis of intervertebral foramina of pelvic regionM99.76 Connective tissue and disc stenosis of intervertebral foramina of lower extremityM99.77 Connective tissue and disc stenosis of intervertebral foramina of upper extremityM99.78 Connective tissue and disc stenosis of intervertebral foramina of rib cageM99.79 Connective tissue and disc stenosis of intervertebral foramina of abdomen and other regionsQ05.0 Cervical spina bifida with hydrocephalusQ05.1 Thoracic spina bifida with hydrocephalusQ05.2 Lumbar spina bifida with hydrocephalusQ05.3 Sacral spina bifida with hydrocephalusQ05.4 Unspecified spina bifida with hydrocephalusQ05.5 Cervical spina bifida without hydrocephalusQ05.6 Thoracic spina bifida without hydrocephalusQ05.7 Lumbar spina bifida without hydrocephalusPrinted on 9/21/2015. Page 26 of 40


Q05.8 Sacral spina bifida without hydrocephalusQ05.9 Spina bifida, unspecifiedQ06.2 DiastematomyeliaQ07.00 Arnold-Chiari syndrome without spina bifida or hydrocephalusQ07.01 Arnold-Chiari syndrome with spina bifidaQ07.02 Arnold-Chiari syndrome with hydrocephalusQ07.03 Arnold-Chiari syndrome with spina bifida and hydrocephalusQ68.0 Congenital deformity of sternocleidomastoid muscleQ85.00 Neurofibromatosis, unspecifiedQ85.01 Neurofibromatosis, type 1Q85.02 Neurofibromatosis, type 2Q85.03 SchwannomatosisQ85.09 Other neurofibromatosisR15.9 Full incontinence of fecesR20.0 Anesthesia of skinR20.1 Hypoesthesia of skinR20.2 Paresthesia of skinR20.3 HyperesthesiaR20.8 Other disturbances of skin sensationR20.9 Unspecified disturbances of skin sensationR25.0 Abnormal head movementsR25.1 Tremor, unspecifiedR25.2 Cramp and spasmR25.3 FasciculationR25.8 Other abnormal involuntary movementsR25.9 Unspecified abnormal involuntary movementsR26.0 Ataxic gaitR26.1 Paralytic gaitR26.81 Unsteadiness on feetR26.89 Other abnormalities of gait and mobilityR26.9 Unspecified abnormalities of gait and mobilityR27.0 Ataxia, unspecifiedR27.8 Other lack of coordinationR27.9 Unspecified lack of coordinationR29.0 TetanyR29.1 MeningismusR29.5 Transient paralysisR29.898 Other symptoms and signs involving the musculoskeletal systemR41.1 Anterograde amnesiaR41.2 Retrograde amnesiaR41.3 Other amnesiaR41.9 Unspecified symptoms and signs involving cognitive functions and awarenessR45.83 Excessive crying of child, adolescent or adultR45.84 AnhedoniaR47.02 DysphasiaR47.1 Dysarthria and anarthriaR47.81 Slurred speechR47.82 Fluency disorder in conditions classified elsewhereR47.89 Other speech disturbancesR47.9 Unspecified speech disturbancesR49.0 DysphoniaR49.1 AphoniaR49.21 HypernasalityR49.22 HyponasalityR49.8 Other voice and resonance disordersR49.9 Unspecified voice and resonance disorderR53.0 Neoplastic (malignant) related fatigue



R53.1 WeaknessR53.81 Other malaiseR53.83 Other fatigueR68.81 Early satietyR68.89 Other general symptoms and signsR94.131 Abnormal electromyogram [EMG]S04.50XA Injury of facial nerve, unspecified side, initial encounterS04.51XA Injury of facial nerve, right side, initial encounterS04.52XA Injury of facial nerve, left side, initial encounterS04.70XA Injury of accessory nerve, unspecified side, initial encounterS04.71XA Injury of accessory nerve, right side, initial encounterS04.72XA Injury of accessory nerve, left side, initial encounterS04.811A Injury of olfactory [1st ] nerve, right side, initial encounterS04.812A Injury of olfactory [1st ] nerve, left side, initial encounterS04.819A Injury of olfactory [1st ] nerve, unspecified side, initial encounterS04.891A Injury of other cranial nerves, right side, initial encounterS04.892A Injury of other cranial nerves, left side, initial encounterS04.899A Injury of other cranial nerves, unspecified side, initial encounterS12.000A Unspecified displaced fracture of first cervical vertebra, initial encounter for closed fractureS12.000B Unspecified displaced fracture of first cervical vertebra, initial encounter for open fractureS12.001A Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for closed fractureS12.001B Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for open fractureS12.100A Unspecified displaced fracture of second cervical vertebra, initial encounter for closed fractureS12.100B Unspecified displaced fracture of second cervical vertebra, initial encounter for open fractureS12.101A Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for closed fractureS12.101B Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for open fractureS12.200A Unspecified displaced fracture of third cervical vertebra, initial encounter for closed fractureS12.200B Unspecified displaced fracture of third cervical vertebra, initial encounter for open fractureS12.201A Unspecified nondisplaced fracture of third cervical vertebra, initial encounter for closed fractureS12.201B Unspecified nondisplaced fracture of third cervical vertebra, initial encounter for open fractureS12.300A Unspecified displaced fracture of fourth cervical vertebra, initial encounter for closed fractureS12.300B Unspecified displaced fracture of fourth cervical vertebra, initial encounter for open fractureS12.301A Unspecified nondisplaced fracture of fourth cervical vertebra, initial encounter for closed fractureS12.301B Unspecified nondisplaced fracture of fourth cervical vertebra, initial encounter for open fractureS12.400A Unspecified displaced fracture of fifth cervical vertebra, initial encounter for closed fractureS12.400B Unspecified displaced fracture of fifth cervical vertebra, initial encounter for open fractureS12.401A Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fractureS12.401B Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for open fractureS12.500A Unspecified displaced fracture of sixth cervical vertebra, initial encounter for closed fractureS12.500B Unspecified displaced fracture of sixth cervical vertebra, initial encounter for open fractureS12.501A Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter for closed fractureS12.501B Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter for open fractureS12.600A Unspecified displaced fracture of seventh cervical vertebra, initial encounter for closed fractureS12.600B Unspecified displaced fracture of seventh cervical vertebra, initial encounter for open fractureS12.601A Unspecified nondisplaced fracture of seventh cervical vertebra, initial encounter for closed fractureS12.601B Unspecified nondisplaced fracture of seventh cervical vertebra, initial encounter for open fractureS12.9XXA Fracture of neck, unspecified, initial encounterS14.0XXA Concussion and edema of cervical spinal cord, initial encounterS14.101A Unspecified injury at C1 level of cervical spinal cord, initial encounterS14.102A Unspecified injury at C2 level of cervical spinal cord, initial encounterS14.103A Unspecified injury at C3 level of cervical spinal cord, initial encounterS14.104A Unspecified injury at C4 level of cervical spinal cord, initial encounterS14.105A Unspecified injury at C5 level of cervical spinal cord, initial encounterS14.106A Unspecified injury at C6 level of cervical spinal cord, initial encounterS14.107A Unspecified injury at C7 level of cervical spinal cord, initial encounterS14.108A Unspecified injury at C8 level of cervical spinal cord, initial encounterS14.109A Unspecified injury at unspecified level of cervical spinal cord, initial encounterS14.111A Complete lesion at C1 level of cervical spinal cord, initial encounterPrinted on 9/21/2015. Page 28 of 40


S14.112A Complete lesion at C2 level of cervical spinal cord, initial encounterS14.113A Complete lesion at C3 level of cervical spinal cord, initial encounterS14.114A Complete lesion at C4 level of cervical spinal cord, initial encounterS14.115A Complete lesion at C5 level of cervical spinal cord, initial encounterS14.116A Complete lesion at C6 level of cervical spinal cord, initial encounterS14.117A Complete lesion at C7 level of cervical spinal cord, initial encounterS14.118A Complete lesion at C8 level of cervical spinal cord, initial encounterS14.119A Complete lesion at unspecified level of cervical spinal cord, initial encounterS14.121A Central cord syndrome at C1 level of cervical spinal cord, initial encounterS14.122A Central cord syndrome at C2 level of cervical spinal cord, initial encounterS14.123A Central cord syndrome at C3 level of cervical spinal cord, initial encounterS14.124A Central cord syndrome at C4 level of cervical spinal cord, initial encounterS14.125A Central cord syndrome at C5 level of cervical spinal cord, initial encounterS14.126A Central cord syndrome at C6 level of cervical spinal cord, initial encounterS14.127A Central cord syndrome at C7 level of cervical spinal cord, initial encounterS14.128A Central cord syndrome at C8 level of cervical spinal cord, initial encounterS14.129A Central cord syndrome at unspecified level of cervical spinal cord, initial encounterS14.131A Anterior cord syndrome at C1 level of cervical spinal cord, initial encounterS14.132A Anterior cord syndrome at C2 level of cervical spinal cord, initial encounterS14.133A Anterior cord syndrome at C3 level of cervical spinal cord, initial encounterS14.134A Anterior cord syndrome at C4 level of cervical spinal cord, initial encounterS14.135A Anterior cord syndrome at C5 level of cervical spinal cord, initial encounterS14.136A Anterior cord syndrome at C6 level of cervical spinal cord, initial encounterS14.137A Anterior cord syndrome at C7 level of cervical spinal cord, initial encounterS14.138A Anterior cord syndrome at C8 level of cervical spinal cord, initial encounterS14.139A Anterior cord syndrome at unspecified level of cervical spinal cord, initial encounterS14.141A Brown-Sequard syndrome at C1 level of cervical spinal cord, initial encounterS14.142A Brown-Sequard syndrome at C2 level of cervical spinal cord, initial encounterS14.143A Brown-Sequard syndrome at C3 level of cervical spinal cord, initial encounterS14.144A Brown-Sequard syndrome at C4 level of cervical spinal cord, initial encounterS14.145A Brown-Sequard syndrome at C5 level of cervical spinal cord, initial encounterS14.146A Brown-Sequard syndrome at C6 level of cervical spinal cord, initial encounterS14.147A Brown-Sequard syndrome at C7 level of cervical spinal cord, initial encounterS14.148A Brown-Sequard syndrome at C8 level of cervical spinal cord, initial encounterS14.149A Brown-Sequard syndrome at unspecified level of cervical spinal cord, initial encounterS14.151A Other incomplete lesion at C1 level of cervical spinal cord, initial encounterS14.152A Other incomplete lesion at C2 level of cervical spinal cord, initial encounterS14.153A Other incomplete lesion at C3 level of cervical spinal cord, initial encounterS14.154A Other incomplete lesion at C4 level of cervical spinal cord, initial encounterS14.155A Other incomplete lesion at C5 level of cervical spinal cord, initial encounterS14.156A Other incomplete lesion at C6 level of cervical spinal cord, initial encounterS14.157A Other incomplete lesion at C7 level of cervical spinal cord, initial encounterS14.158A Other incomplete lesion at C8 level of cervical spinal cord, initial encounterS14.159A Other incomplete lesion at unspecified level of cervical spinal cord, initial encounterS14.2XXA Injury of nerve root of cervical spine, initial encounterS14.3XXA Injury of brachial plexus, initial encounterS14.4XXA Injury of peripheral nerves of neck, initial encounterS14.5XXA Injury of cervical sympathetic nerves, initial encounterS14.8XXA Injury of other specified nerves of neck, initial encounterS14.9XXA Injury of unspecified nerves of neck, initial encounterS22.009A Unspecified fracture of unspecified thoracic vertebra, initial encounter for closed fractureS22.009B Unspecified fracture of unspecified thoracic vertebra, initial encounter for open fractureS22.019A Unspecified fracture of first thoracic vertebra, initial encounter for closed fractureS22.019B Unspecified fracture of first thoracic vertebra, initial encounter for open fractureS22.029A Unspecified fracture of second thoracic vertebra, initial encounter for closed fractureS22.029B Unspecified fracture of second thoracic vertebra, initial encounter for open fractureS22.039A Unspecified fracture of third thoracic vertebra, initial encounter for closed fracture



S22.039B Unspecified fracture of third thoracic vertebra, initial encounter for open fractureS22.049A Unspecified fracture of fourth thoracic vertebra, initial encounter for closed fractureS22.049B Unspecified fracture of fourth thoracic vertebra, initial encounter for open fractureS22.059A Unspecified fracture of T5-T6 vertebra, initial encounter for closed fractureS22.059B Unspecified fracture of T5-T6 vertebra, initial encounter for open fractureS22.069A Unspecified fracture of T7-T8 vertebra, initial encounter for closed fractureS22.069B Unspecified fracture of T7-T8 vertebra, initial encounter for open fractureS22.079A Unspecified fracture of T9-T10 vertebra, initial encounter for closed fractureS22.079B Unspecified fracture of T9-T10 vertebra, initial encounter for open fractureS22.089A Unspecified fracture of T11-T12 vertebra, initial encounter for closed fractureS22.089B Unspecified fracture of T11-T12 vertebra, initial encounter for open fractureS24.0XXA Concussion and edema of thoracic spinal cord, initial encounterS24.101A Unspecified injury at T1 level of thoracic spinal cord, initial encounterS24.102A Unspecified injury at T2-T6 level of thoracic spinal cord, initial encounterS24.103A Unspecified injury at T7-T10 level of thoracic spinal cord, initial encounterS24.104A Unspecified injury at T11-T12 level of thoracic spinal cord, initial encounterS24.109A Unspecified injury at unspecified level of thoracic spinal cord, initial encounterS24.111A Complete lesion at T1 level of thoracic spinal cord, initial encounterS24.112A Complete lesion at T2-T6 level of thoracic spinal cord, initial encounterS24.113A Complete lesion at T7-T10 level of thoracic spinal cord, initial encounterS24.114A Complete lesion at T11-T12 level of thoracic spinal cord, initial encounterS24.119A Complete lesion at unspecified level of thoracic spinal cord, initial encounterS24.131A Anterior cord syndrome at T1 level of thoracic spinal cord, initial encounterS24.132A Anterior cord syndrome at T2-T6 level of thoracic spinal cord, initial encounterS24.133A Anterior cord syndrome at T7-T10 level of thoracic spinal cord, initial encounterS24.134A Anterior cord syndrome at T11-T12 level of thoracic spinal cord, initial encounterS24.139A Anterior cord syndrome at unspecified level of thoracic spinal cord, initial encounterS24.141A Brown-Sequard syndrome at T1 level of thoracic spinal cord, initial encounterS24.142A Brown-Sequard syndrome at T2-T6 level of thoracic spinal cord, initial encounterS24.143A Brown-Sequard syndrome at T7-T10 level of thoracic spinal cord, initial encounterS24.144A Brown-Sequard syndrome at T11-T12 level of thoracic spinal cord, initial encounterS24.149A Brown-Sequard syndrome at unspecified level of thoracic spinal cord, initial encounterS24.151A Other incomplete lesion at T1 level of thoracic spinal cord, initial encounterS24.152A Other incomplete lesion at T2-T6 level of thoracic spinal cord, initial encounterS24.153A Other incomplete lesion at T7-T10 level of thoracic spinal cord, initial encounterS24.154A Other incomplete lesion at T11-T12 level of thoracic spinal cord, initial encounterS24.159A Other incomplete lesion at unspecified level of thoracic spinal cord, initial encounterS24.2XXA Injury of nerve root of thoracic spine, initial encounterS24.3XXA Injury of peripheral nerves of thorax, initial encounterS24.4XXA Injury of thoracic sympathetic nervous system, initial encounterS24.8XXA Injury of other specified nerves of thorax, initial encounterS24.9XXA Injury of unspecified nerve of thorax, initial encounterS32.009A Unspecified fracture of unspecified lumbar vertebra, initial encounter for closed fractureS32.009B Unspecified fracture of unspecified lumbar vertebra, initial encounter for open fractureS32.019A Unspecified fracture of first lumbar vertebra, initial encounter for closed fractureS32.019B Unspecified fracture of first lumbar vertebra, initial encounter for open fractureS32.029A Unspecified fracture of second lumbar vertebra, initial encounter for closed fractureS32.029B Unspecified fracture of second lumbar vertebra, initial encounter for open fractureS32.039A Unspecified fracture of third lumbar vertebra, initial encounter for closed fractureS32.039B Unspecified fracture of third lumbar vertebra, initial encounter for open fractureS32.049A Unspecified fracture of fourth lumbar vertebra, initial encounter for closed fractureS32.049B Unspecified fracture of fourth lumbar vertebra, initial encounter for open fractureS32.059A Unspecified fracture of fifth lumbar vertebra, initial encounter for closed fractureS32.059B Unspecified fracture of fifth lumbar vertebra, initial encounter for open fractureS32.10XA Unspecified fracture of sacrum, initial encounter for closed fractureS32.10XB Unspecified fracture of sacrum, initial encounter for open fractureS32.2XXA Fracture of coccyx, initial encounter for closed fractureS32.2XXB Fracture of coccyx, initial encounter for open fracturePrinted on 9/21/2015. Page 30 of 40


S34.01XA Concussion and edema of lumbar spinal cord, initial encounterS34.02XA Concussion and edema of sacral spinal cord, initial encounterS34.101A Unspecified injury to L1 level of lumbar spinal cord, initial encounterS34.102A Unspecified injury to L2 level of lumbar spinal cord, initial encounterS34.103A Unspecified injury to L3 level of lumbar spinal cord, initial encounterS34.104A Unspecified injury to L4 level of lumbar spinal cord, initial encounterS34.105A Unspecified injury to L5 level of lumbar spinal cord, initial encounterS34.109A Unspecified injury to unspecified level of lumbar spinal cord, initial encounterS34.111A Complete lesion of L1 level of lumbar spinal cord, initial encounterS34.112A Complete lesion of L2 level of lumbar spinal cord, initial encounterS34.113A Complete lesion of L3 level of lumbar spinal cord, initial encounterS34.114A Complete lesion of L4 level of lumbar spinal cord, initial encounterS34.115A Complete lesion of L5 level of lumbar spinal cord, initial encounterS34.119A Complete lesion of unspecified level of lumbar spinal cord, initial encounterS34.121A Incomplete lesion of L1 level of lumbar spinal cord, initial encounterS34.122A Incomplete lesion of L2 level of lumbar spinal cord, initial encounterS34.123A Incomplete lesion of L3 level of lumbar spinal cord, initial encounterS34.124A Incomplete lesion of L4 level of lumbar spinal cord, initial encounterS34.125A Incomplete lesion of L5 level of lumbar spinal cord, initial encounterS34.129A Incomplete lesion of unspecified level of lumbar spinal cord, initial encounterS34.131A Complete lesion of sacral spinal cord, initial encounterS34.132A Incomplete lesion of sacral spinal cord, initial encounterS34.139A Unspecified injury to sacral spinal cord, initial encounterS34.21XA Injury of nerve root of lumbar spine, initial encounterS34.22XA Injury of nerve root of sacral spine, initial encounterS34.3XXA Injury of cauda equina, initial encounterS34.4XXA Injury of lumbosacral plexus, initial encounterS34.5XXA Injury of lumbar, sacral and pelvic sympathetic nerves, initial encounterS34.6XXA Injury of peripheral nerve(s) at abdomen, lower back and pelvis level, initial encounterS34.8XXA Injury of other nerves at abdomen, lower back and pelvis level, initial encounterS34.9XXA Injury of unspecified nerves at abdomen, lower back and pelvis level, initial encounterS44.00XA Injury of ulnar nerve at upper arm level, unspecified arm, initial encounterS44.01XA Injury of ulnar nerve at upper arm level, right arm, initial encounterS44.02XA Injury of ulnar nerve at upper arm level, left arm, initial encounterS44.10XA Injury of median nerve at upper arm level, unspecified arm, initial encounterS44.11XA Injury of median nerve at upper arm level, right arm, initial encounterS44.12XA Injury of median nerve at upper arm level, left arm, initial encounterS44.20XA Injury of radial nerve at upper arm level, unspecified arm, initial encounterS44.21XA Injury of radial nerve at upper arm level, right arm, initial encounterS44.22XA Injury of radial nerve at upper arm level, left arm, initial encounterS44.30XA Injury of axillary nerve, unspecified arm, initial encounterS44.31XA Injury of axillary nerve, right arm, initial encounterS44.32XA Injury of axillary nerve, left arm, initial encounterS44.40XA Injury of musculocutaneous nerve, unspecified arm, initial encounterS44.41XA Injury of musculocutaneous nerve, right arm, initial encounterS44.42XA Injury of musculocutaneous nerve, left arm, initial encounter

S44.50XA Injury of cutaneous sensory nerve at shoulder and upper arm level, unspecified arm, initialencounter

S44.51XA Injury of cutaneous sensory nerve at shoulder and upper arm level, right arm, initial encounterS44.52XA Injury of cutaneous sensory nerve at shoulder and upper arm level, left arm, initial encounterS44.8X1A Injury of other nerves at shoulder and upper arm level, right arm, initial encounterS44.8X2A Injury of other nerves at shoulder and upper arm level, left arm, initial encounterS44.8X9A Injury of other nerves at shoulder and upper arm level, unspecified arm, initial encounterS44.90XA Injury of unspecified nerve at shoulder and upper arm level, unspecified arm, initial encounterS44.91XA Injury of unspecified nerve at shoulder and upper arm level, right arm, initial encounterS44.92XA Injury of unspecified nerve at shoulder and upper arm level, left arm, initial encounterS54.00XA Injury of ulnar nerve at forearm level, unspecified arm, initial encounterS54.01XA Injury of ulnar nerve at forearm level, right arm, initial encounterPrinted on 9/21/2015. Page 31 of 40


S54.02XA Injury of ulnar nerve at forearm level, left arm, initial encounterS54.10XA Injury of median nerve at forearm level, unspecified arm, initial encounterS54.11XA Injury of median nerve at forearm level, right arm, initial encounterS54.12XA Injury of median nerve at forearm level, left arm, initial encounterS54.20XA Injury of radial nerve at forearm level, unspecified arm, initial encounterS54.21XA Injury of radial nerve at forearm level, right arm, initial encounterS54.22XA Injury of radial nerve at forearm level, left arm, initial encounterS54.30XA Injury of cutaneous sensory nerve at forearm level, unspecified arm, initial encounterS54.31XA Injury of cutaneous sensory nerve at forearm level, right arm, initial encounterS54.32XA Injury of cutaneous sensory nerve at forearm level, left arm, initial encounterS54.8X1A Unspecified injury of other nerves at forearm level, right arm, initial encounterS54.8X2A Unspecified injury of other nerves at forearm level, left arm, initial encounterS54.8X9A Unspecified injury of other nerves at forearm level, unspecified arm, initial encounterS54.90XA Injury of unspecified nerve at forearm level, unspecified arm, initial encounterS54.91XA Injury of unspecified nerve at forearm level, right arm, initial encounterS54.92XA Injury of unspecified nerve at forearm level, left arm, initial encounterS64.00XA Injury of ulnar nerve at wrist and hand level of unspecified arm, initial encounterS64.01XA Injury of ulnar nerve at wrist and hand level of right arm, initial encounterS64.02XA Injury of ulnar nerve at wrist and hand level of left arm, initial encounterS64.10XA Injury of median nerve at wrist and hand level of unspecified arm, initial encounterS64.11XA Injury of median nerve at wrist and hand level of right arm, initial encounterS64.12XA Injury of median nerve at wrist and hand level of left arm, initial encounterS64.20XA Injury of radial nerve at wrist and hand level of unspecified arm, initial encounterS64.21XA Injury of radial nerve at wrist and hand level of right arm, initial encounterS64.22XA Injury of radial nerve at wrist and hand level of left arm, initial encounterS64.30XA Injury of digital nerve of unspecified thumb, initial encounterS64.31XA Injury of digital nerve of right thumb, initial encounterS64.32XA Injury of digital nerve of left thumb, initial encounterS64.40XA Injury of digital nerve of unspecified finger, initial encounterS64.490A Injury of digital nerve of right index finger, initial encounterS64.491A Injury of digital nerve of left index finger, initial encounterS64.492A Injury of digital nerve of right middle finger, initial encounterS64.493A Injury of digital nerve of left middle finger, initial encounterS64.494A Injury of digital nerve of right ring finger, initial encounterS64.495A Injury of digital nerve of left ring finger, initial encounterS64.496A Injury of digital nerve of right little finger, initial encounterS64.497A Injury of digital nerve of left little finger, initial encounterS64.498A Injury of digital nerve of other finger, initial encounterS64.8X1A Injury of other nerves at wrist and hand level of right arm, initial encounterS64.8X2A Injury of other nerves at wrist and hand level of left arm, initial encounterS64.8X9A Injury of other nerves at wrist and hand level of unspecified arm, initial encounterS64.90XA Injury of unspecified nerve at wrist and hand level of unspecified arm, initial encounterS64.91XA Injury of unspecified nerve at wrist and hand level of right arm, initial encounterS64.92XA Injury of unspecified nerve at wrist and hand level of left arm, initial encounterS74.00XA Injury of sciatic nerve at hip and thigh level, unspecified leg, initial encounterS74.01XA Injury of sciatic nerve at hip and thigh level, right leg, initial encounterS74.02XA Injury of sciatic nerve at hip and thigh level, left leg, initial encounterS74.10XA Injury of femoral nerve at hip and thigh level, unspecified leg, initial encounterS74.11XA Injury of femoral nerve at hip and thigh level, right leg, initial encounterS74.12XA Injury of femoral nerve at hip and thigh level, left leg, initial encounterS74.20XA Injury of cutaneous sensory nerve at hip and thigh level, unspecified leg, initial encounterS74.21XA Injury of cutaneous sensory nerve at hip and high level, right leg, initial encounterS74.22XA Injury of cutaneous sensory nerve at hip and thigh level, left leg, initial encounterS74.8X1A Injury of other nerves at hip and thigh level, right leg, initial encounterS74.8X2A Injury of other nerves at hip and thigh level, left leg, initial encounterS74.8X9A Injury of other nerves at hip and thigh level, unspecified leg, initial encounterS74.90XA Injury of unspecified nerve at hip and thigh level, unspecified leg, initial encounter



S74.91XA Injury of unspecified nerve at hip and thigh level, right leg, initial encounterS74.92XA Injury of unspecified nerve at hip and thigh level, left leg, initial encounterS84.00XA Injury of tibial nerve at lower leg level, unspecified leg, initial encounterS84.01XA Injury of tibial nerve at lower leg level, right leg, initial encounterS84.02XA Injury of tibial nerve at lower leg level, left leg, initial encounterS84.10XA Injury of peroneal nerve at lower leg level, unspecified leg, initial encounterS84.11XA Injury of peroneal nerve at lower leg level, right leg, initial encounterS84.12XA Injury of peroneal nerve at lower leg level, left leg, initial encounterS84.20XA Injury of cutaneous sensory nerve at lower leg level, unspecified leg, initial encounterS84.21XA Injury of cutaneous sensory nerve at lower leg level, right leg, initial encounterS84.22XA Injury of cutaneous sensory nerve at lower leg level, left leg, initial encounterS84.801A Injury of other nerves at lower leg level, right leg, initial encounterS84.802A Injury of other nerves at lower leg level, left leg, initial encounterS84.809A Injury of other nerves at lower leg level, unspecified leg, initial encounterS84.90XA Injury of unspecified nerve at lower leg level, unspecified leg, initial encounterS84.91XA Injury of unspecified nerve at lower leg level, right leg, initial encounterS84.92XA Injury of unspecified nerve at lower leg level, left leg, initial encounterS94.00XA Injury of lateral plantar nerve, unspecified leg, initial encounterS94.01XA Injury of lateral plantar nerve, right leg, initial encounterS94.02XA Injury of lateral plantar nerve, left leg, initial encounterS94.10XA Injury of medial plantar nerve, unspecified leg, initial encounterS94.11XA Injury of medial plantar nerve, right leg, initial encounterS94.12XA Injury of medial plantar nerve, left leg, initial encounterS94.20XA Injury of deep peroneal nerve at ankle and foot level, unspecified leg, initial encounterS94.21XA Injury of deep peroneal nerve at ankle and foot level, right leg, initial encounterS94.22XA Injury of deep peroneal nerve at ankle and foot level, left leg, initial encounterS94.30XA Injury of cutaneous sensory nerve at ankle and foot level, unspecified leg, initial encounterS94.31XA Injury of cutaneous sensory nerve at ankle and foot level, right leg, initial encounterS94.32XA Injury of cutaneous sensory nerve at ankle and foot level, left leg, initial encounterS94.8X1A Injury of other nerves at ankle and foot level, right leg, initial encounterS94.8X2A Injury of other nerves at ankle and foot level, left leg, initial encounterS94.8X9A Injury of other nerves at ankle and foot level, unspecified leg, initial encounterS94.90XA Injury of unspecified nerve at ankle and foot level, unspecified leg, initial encounterS94.91XA Injury of unspecified nerve at ankle and foot level, right leg, initial encounterS94.92XA Injury of unspecified nerve at ankle and foot level, left leg, initial encounter

ICD-10 Codes DescriptionG56.00 Carpal tunnel syndrome, unspecified upper limbG56.01 Carpal tunnel syndrome, right upper limbG56.02 Carpal tunnel syndrome, left upper limb

ICD-10 Codes DescriptionXX000 Not Applicable

Group 2 Paragraph: ICD-10-CM codes that support medical necessity of procedure code 95905:

Group 2 Codes:

ICD-10 Codes that DO NOT Support Medical NecessityGroup 1 Paragraph: All those not listed under the "ICD-10 Codes that Support Medical Necessity" section of thispolicy.

Group 1 Codes:

ICD-10 Additional Information


1. All documentation must be maintained in the patient’s medical record and made available to thecontractor upon request.

2. Every page of the record must be legible and include appropriate patient identification information (e.g.,complete name, dates of service(s)). The documentation must include the legible signature of thephysician or non-physician practitioner responsible for and providing the care to the patient.

3. The submitted medical record should support the use of the selected ICD-10-CM code(s). The submittedCPT/HCPCS code must describe the service performed.

4. The medical record documentation must support the medical necessity of the services as directed in thispolicy.

5. Data gathered during NCS, however, should be available which reflect the actual numbers (latency,amplitude, etc.), preferably in a tabular (not narrative) format. The reason for referral and a cleardiagnostic impression are required for each study. In cases where a review becomes necessary, either ahard copy of waveforms or a complete written report with an interpretation of the test must be submittedupon request.

6. Normal findings and abnormalities uncovered during the study should be documented with the musclestested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unitpotentials and interpretation.

Conditions

LimbStudies

byNeedle

EMG(95860-95864,95867-95870)

NerveConduction

StudiesTotal

NervesStudied

(95907, 95913)

NeuromuscularJunctionTesting

RepetitiveStimulation

(95937)

Carpal Tunnel (Unilateral) 1 7 Not Applicable

Carpal Tunnel (Bilateral) 2 10 Not Applicable

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General Information

Associated InformationOther Information

Refer to LCD L34977 for information on Anorectal Manometry, Anal Electromyography, and Biofeedback Trainingfor Perineal Muscles and Anorectal or Urethral Sphincters.

Refer to LCD L34996 for more detailed guidelines on Neuromuscular Junction Testing.

Refer to LCD L35003 for more detailed guidelines on Intraoperative Neurophysiological Testing.

Documentation Requirements

Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptablestandards of practice.

95905 is covered only once per upper extremity limb per patient per year for a diagnosis of carpal tunnelsyndrome (G56.00, G56.01 or G56.02).

Excessive use of units of testing (see table immediately below, based on a White Paper prepared by the AmericanAssociation of Electrodiagnostic Medicine) will be considered not medically necessary. Consistent repeated testingon the same patient, or testing every patient referred for pain, weakness or paresthesia may become evident onreview. In such cases, the claim will be considered not medically necessary. The NCS-EMG performing provider,in consultation with the referring provider, is responsible for determination of the appropriateness of a study.


Conditions

LimbStudies

byNeedle

EMG(95860-95864,95867-95870)

NerveConduction

StudiesTotal

NervesStudied

(95907, 95913)

NeuromuscularJunctionTesting

RepetitiveStimulation

(95937)

Radiculopathy 2 7 Not Applicable

Mononeuropathy 1 8 Not Applicable

Polyneuropathy/Mononeuropathy Mulitplex 3 10 Not ApplicableMyopathy 2 4 2

Motor Neuronopathy (eg, ALS) 4 6 2

Plexopathy 2 12 Not ApplicableNeuromuscular Junction 2 4 3Tarsal Tunnel Syndrome (Unilateral) 1 8 Not ApplicableTarsal Tunnel Syndrome (Bilateral) 2 11 Not ApplicableWeakness, Fatigue, Cramps, or Twitching (Focal) 2 7 2

Weakness, Fatigue, Cramps, or Twitching (General) 4 8 2

Pain, Numbness, or Tingling (Unilateral) 1 9 Not Applicable

Pain, Numbness, or Tingling (Bilateral) 2 12 Not Applicable

Testing of the contralateral limb must be supported by medical necessity.

Sources of Information and Basis for DecisionContractor is not responsible for the continued viability of websites listed.

AANEM Recommended Policy for Electrodiagnostic Medicine. Available at:http://www.aan.com/globals/axon/assets/4061.pdf

AANEM Position Statement, Muscle Nerve 33: 436-439, 2006

AANEM Practice Topics, September, 2006

ABPTS. Clinical Electrophysiologic Physical Therapy: Description of Specialty Practice. Alexandria, VA. 2005.

ABPTS. 2011 Physical Therapy Specialist Clinical Electrophysiology Certification Examination Application &Information Booklet. 2010. Available at: http//www.apta.org.

American Association of Electrodiagnostic Medicine Position Statement - Recommended Policy forElectrodiagnostic Medicine

American Association of Electrodiagnostic Medicine Position Statement - Technologists Conducting NerveConduction Studies and Somatosensory Evoked Potential Studies Independently to be reviewed by a Physician ata Later Time

Albers JW, et al., Subclinical Neuropathy Among Diabetes Control and Complications Trial Participants WithoutDiagnosable Neuropathy at Trial Completion. Diabetes Care. Oct. 2007; 30(10): 2613-2618.

APTA. Electrophysiologic Examination and Evaluation Position Statement. June 1985. HOD P06-96-20-04.Available at: http//www.apta.org.


Armstrong TH, Dale AM, Al-Lozi MT et al. Median and Ulnar Conduction Studies at the Wrist; Criterion Validity ofthe NC-Stat Automated Device: J Occup Environ Med. 2008; 50:758-764.

Bird SJ, et al. Value of Repeated Measures of Nerve Conduction and Quantitative Sensory Testing in a DiabeticNeuropathy Trial: Muscle and Nerve. August 2006: 214-224.

Boulton AJM, et al. Diabetic Neuropathies: Diabetes Care. 2005; 28 (4): 956-962

Bril V, et al. Ranirestat for the Management of Diabetic Sensorimotor Polyneuropathy: Diabetes Care. July 2009;32: 1256-1260.

Brown E. An Evidence Based Technology Assessment of the NC-stat® Device; March 19, 2007

Burke D, et al. Sensory Conduction for the Sural Nerve in Polyneuropathy. Journal of Neurology, Neurosurgery,and Psychiatry: 1974; 37: 647-652.

Callaghan B, et al. Tests and Expenditures in the Initial Evaluation of Peripheral Neuropathy. Arch Intern Med Jan23, 2012; 172 (2): 127-132.

Charles M, et al. Low Peripheral Nerve Conduction Velocities and Amplitudes Are Strongly Related to DiabeticMicrovascular Complications in Type 1 Diabetes. Diabetes Care: Dec 2010; 33: 12: 2648-2653.

CMD Neurophysiology Workgroup Review Model Policy for Electromyography

Consultants in Various Specialties

Department of Health and Human Services Office of the Inspector General Work Plan Fiscal Year 2004. Availableat http://oig.hhs.gov/reading/workplan/2004/Work%20Plan% 202004.pdf Accessed September 13, 2005.

Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications ResearchGroup Writing Team. Effect of Intensive Therapy on the Microvascular Complications of Type 1 Diabetes Mellitus.JAMA: May 2002; 287 (19): 2563-2569.

Dros J, et al. Accuracy of Monofilament Testing to Diagnose Peripheral Neuropathy: A Systematic Review. Annalsof Family Medicine. 2009; 7 (6): 555-558.

Dyck PJ, et al. Diabetic Polyneuropathies: Update on Research Definition, Diagnostic Criteria and Estimation ofSeverity. Diabetes Metab Res Rev 2011; 27:620-628.

Dyck PJ, et al. Modeling Chronic Glycemic Exposure Variables as Correlates and Predictors of MicrovascularComplications of Diabetes. Diabetes Care. Oct. 2006; 29(10): 2282-2288.

Dyck PJ, et al. Clinical and Neuropathological Criteria For the Diagnosis and Staging of Diabetic Polyneuropathy.Brain: 1985; 108: 861-880.

Dyck PJ, et al. The Prevalence by Staged Severity of Carious Types of Diabetic Neuropathy, Retinopathy, andNephropathy in a Population-Based Cohort: The Rochester Diabetic Neuropathy Study. Neurology. April 1993; 43:817-824.

Dyck PJ, et al., Monotonicity of Nerve Tests in Diabetes. Diabetes Care. Sept 2005; 28 (9): 2192-2200.

Dyck PJ, et al., Signs and Symptoms Versus Nerve Conduction Studies to Diagnose Diabetic SensorimotorPolyneuropathy: CI vs. NPhys Trial. Muscle and Nerve. Aug 2010: 157-164.

Elkowitz SJ, Dubin NH, Richards BE, et al. Clinical utility of portable versus traditional electrodiagnostic testing fordiagnosing, evaluating and treating carpal tunnel syndrome. Am J Orthop. 2005; 34(8):362-364.

England JD, et al., Distal Symmetrical Polyneuropathy: Definition for Clinical Research. Muscle and Nerve: Jan2005: 113-123.

Fisher MA, Bajwa J, Somashekar KN. Routine electrodiagnosis and a multiparameter technique in lumbosacralradiculopathies: Acta Neurol Scand. 2008; 118:99-105.

Gordois A., et al. The Health Care Costs of Diabetic peripheral Neuropathy in the U.S. Diabetes Care. June 2003;26 (6): 1790-1795.


Gozani SN, Electrodiagnostic Automation: Principles and Practice. Phys Med Rehabil Clin N Am 2005; 16: 1015-1032.

Harrington C, et al. A Cost Analysis of Diabetic Lower-Extremity Ulcers. Diabetes Care. September 2000; 23 (9):1333-1338.

Harris,SB, Diabetes Management in Canada: Baseline Results of the Group Practice Diabetes Management Study.Canadian Journal of Diabetes. 2006; 30 (2):131-137.

Harwell TS, Foot Care Practices, Services and Perceptions of Risk Among Medicare Beneficiaries With Diabetes atHigh and Low Risk for Future Foot Complications. Foot and Ankle International. Sept. 2001; 22 (9): 734-738.

Hilburn JW, General principles and use of electrodiagnostic studies in carpal and cubital tunnel syndrome. Withspecial attention to pitfalls and interpretation. Hand Clin. 1996; 12(2):205-221.

HSY WC, Somatic Neuropathy is an Independent Predictor of All-and Diabetes- Related

Mortality in Type 2 Diabetic Patients: A Population-Based 5-Year Follow-Up Study (KCIS No. 29). EuropeanJournal of Neurology, 2012.

Jabre JF, Criterion Validity of the NC-stat Automated Nerve Conduction Measruement Instrument. Physiol. Meas.2007; 28: 95-104.

Johnsen B, et al. Inter-and Intraobserver Variation in the Interpretation of Electromyographic Tests.Electroencephalography and Clinical Neruophysiology 1995; 97; 432-443.

Katz J, Simon B, Carpal Tunnel Syndrome. New England Journal of Medicine. 2002; 346:1807-1812.

Katz RT, NC-stat as a screening tool for carpal tunnel syndrome in industrial workers. J Occup Environ Med.2006; 48(4):414-418.

Kirkman MS, Impact of a Program to Improve Adherence to Diabetes Guidelines by Primary Care Physicians.Diabetes Care. 2002; 25(11): 1946-1951.

Kiziltan ME, et al., Peripheral Neuropathy in Patients With Diabetic Foot Ulcers: Clinical and Nerve ConductionStudy. Journal of the Neurological Sciences 2007; 258; 75-79.

Kong X, et al., Repeatability of Nerve Conduction Measurements Derived Entirely by Computer Methods.BioMedical Engineering OnLine. 2009; 8:33

Kong X, et al., Utilization of Nerve Conduction Studies for the Diagnosis of Polyneuropathy in Patients withDiabetes: A Retrospective Analysis of a Large Patient Series. Journal of Diabetes Science and Technology. March2008; 2(2): 268-274.

Leffler CT, Gozani SN, Cros D, Median neuropathy at the wrist: diagnostic utility of clinical findings and anautomated electrodiagnostic device. J Occup Environ Med. 2000; 42(4):398-409.

Marshall CL, et al., Outpatient Management of Diabetes Mellitus in Five Arizona Medicare Managed Care Plans.American Journal of Medical Quality. Summer 1996; 11 (2): 87-93.

McInnes A, et al. Consensus Statement: Foot Care Education in Patients with Diabetes at Low Risk ofComplications: A Consensus Statement. Diabetic Medicine 2011: 162-167.

Megeria JT, et al. Utility of Nerve Conduction Studies for Carpal Tunnel Syndrome by Family Medicine, PrimaryCare, and Internal Medicine Physicians. JABFM. 2007; 20 (1): 60-64.

Morse J. NC-stat® System, NeuroMetrix® Inc. (Nerve Conduction Testing System) Technology Assessment: June8, 2006

Morse, J. Office of the Medical Director, Department of Labor and Industries. Washington State Department ofLabor and Industries. Technology Assessment: NC-stat System, NeuroMetrix, Inc. June 8, 2006. Available at:http://www.lni.wa.gov/ClaimsIns/Files/OMD/taNCSTAT0506.pdf

Moss SE, et al., The Prevalence and Incidence of Lower Extremity Amputation in a Diabetic Population. ArchIntern Med. March 1992; 152: 610-616.


Perkins BA, Orszag A, Grewal j, et al. Multi-Site Testing With a Point-of-Care Nerve Conduction Device Can BeUsed in an Algorithm to Diagnose Diabetic Sensorimotor Polyneuropathy; Diabetic Care. 2008; 31:522-524.

Perkins BA, Grewal J, Ng E, et al. Validation of a novel point-of-care nerve conduction device for the detection ofdiabetic sensorimotor polyneuropathy. Diabetes Care. 2006; 29(9):2023-2027.

Pambianco G, et al., Risk Factor Associations With Clinical Distal Symmetrical Polyneuropathy and VariousNeuropathy Screening Instruments and Protocols in Type 1 Diabetes. Diabetes Research and Clinical Practice 91(2011).

Pambianco G, et al., The Assessment of Clinical Distal Symmetric Polyneuropathy in Type 1 Diabetes: AComparison of Methodologies From the Pittsburgh Epidemiology of Diabetes Complications Cohort. DiabetesResearch and Clinical Practice. 2011.

Papanas N, et al., New Diagnostic Tests for Diabetic distal Symmetric Polyneuropathy. Journal of Diabetes and ItsComplications. 2011; 25: 44-51.

Perkins BA, et al., Diabetic Neruopathy: A Review Emphasizing Diagnostic Methods. Clinical Neurophysiology2003; 114: 1167-1175.

Perkins BA, Glycemic Control is Related to the Morphological Severity of Diabetic Sensorimotor Polyneuropathy.Diabetes Care. April 2001; 24 (4): 748-752.

Perkins BA, Validation of a Novel Point-Of Care Nerve Conduction Device for the Detection of DiabeticSensorimotor Polyneuropathy. Diabetes Care Sept. 2006; 29 (9): 2023-2027.

Perkins BA, Simple Screening Tests for Peripheral Neuropathy in the Diabetes Clinic. Diabetes Care. Feb 2001; 24(2): 250-256.

Perkins BA, Multi-Site Testing With a Point-of-Care Nerve Conduction Device Can Be Used in an Algorithm toDiagnose Diabetic Sensorimotor Polyneuorpathy. Diabetes Care. March 2008; 31(3): j522-524.

Salerno DF, et al, Medican and Ulnar Nerve Conduction Studies Among Workers: Normative Values. Muscle andNerve. Aug 1998: 999-1005.

Schmidt K, et. al. Accuracy of Diagnoses Delivered by An Automated Hand-Held Nerve Conduction Device inComparison to Standard Electrophysiological Testing In Patients With Unilateral Leg Symptoms. Muscle andnerve. Jan 2011; 9-13.

Schwartz AV, Diabetes-Related Complications, Glycemic Control and Falls in Older Adults. Diabetes Care. 2008.

Shepherd, M.M. Clinical Outcomes of Electrodiagnostic Testing Conducted in Primary Care. JABFM 2010; 23 (5):584-590.

Singh N, et al. Preventing Foot Ulcers in Patients With Diabetes. JAMA. 2005; 293 (2): 217-228.

Tesfaye S, et al. Diabetic Neuropathies: Update on Definitions, Diagnostic Criteria, Estimation of Severity, andTreatments. Diabetes Care. 2010; 33 (10): 2285-2293.

Tesfaye S, et al. Vascular Risk Factors and Diabetic Neuropathy. NEJM 2005; 352(4):341-350.

U.S. Food and Drug Administration 510(k) Premarket Notification Database. NeuroMetrix NC-stat.® No. K041320.Rockville, MD: FDA. Aug. 12, 2004. Available at: http://www.fda.gov/cdrh/

Veves A, et al. The Relationship Between Sural Nerve Morphometric Findings and Measure of Peripheral NerveFunction in Mild Diabetic Neuropathy. Diabetic Medicine. 1991; 8:917-921.

Vinik AL, Emley MS, Megerian JT, et al. Median and ulnar nerve conduction measurements in patients withsymptoms of diabetic peripheral neuropathy using the NC-stat system. Diabetes Technol Ther. 2004; 6(6):816-824.

Vrancken A, The Meaning of Distal Sensory Loss and Absent Ankle Reflexes in Relation to Age. J Neurol. 2006;253: 578-589.

Werner RA, Cavender GD: Evaluating radiculopathy: how useful is electrodiagnostic testing? Phys Med Rehabil:State of the Art Reviews 1999;13:251–261.AANEMPrinted on 9/21/2015. Page 38 of 40

RevisionHistory

Date

RevisionHistoryNumber

Revision History Explanation Reason(s) for Change

10/01/2015 R6LCD revised and published on 08/13/2015 to remove thestatement "and professional component" from the physicaltherapy designation statement for EMG codes.

• Other (Clarification)

10/01/2015 R5

LCD revised to correct the supervision level for EMG studies.HCPCS code G0255 removed from the Group 2 CPT/HCPCScode list and from the Group 1 ICD-10 paragraph to provideclarification that this service is considered a non-coveredservice by Medicare.

• ProviderEducation/Guidance

• ReconsiderationRequest

10/01/2015 R4

LCD revised to remove group 3 ICD-10 codes from thepolicy since appropriate diagnosis coding for 95937 is foundin LCD L34996, Neuromuscular Junction LCDs. Bill Type75X, Clinic, Comprehensive Outpatient Rehabilitation Centerremoved from policy, Supervision requirements and codinginformation revised and some information removed from thepolicy and placed in Local Coverage Article, A54095.

• Other (Clarification)

10/01/2015 R3

LCD revised and published on 12/11/2014 to add additionalICD-10-CM diagnosis codes that crosswalk to some of thecurrent ICD-9 LCD diagnoses in group 1. Additionaldiagnosis codes for diabetes, rheumatoid arthritis, tics, andpolymyositis were added to this future effective LCD.

• Other (Request foraddition ofcoverage byspecialtyassociation. )

10/01/2015 R2

LCD revised and published on 08/14/2014 to reflect changesto the annual ICD-10-CM updates. ICD-10-CM codesM47.17, M47.18, and M51.07 were removed from thepolicy. ICD-10-CM codes M50.01, M50.11, M50.21, M50.31,M50.81, and M50.91 have undergone descriptor changeswhich have been reflected in the policy.

• Revisions Due ToICD-10-CM CodeChanges

10/01/2015 R1 LCD updated to correct typographical and grammaticalerrors. (LCD updated 06/12/2014) • Typographical Error

Wilbourn AJ, et al. Sensory Nerve Conduction Studies. J Clin. Neurophysiol. 1994; 11 (6): 584-601.

Other Contractor(s)' Policies

Contractor Medical Directors

Original JH ICD-9 Source LCD L32723, Nerve Conduction Studies and ElectromyographyBack to Top

Revision History InformationPlease note: Most Revision History entries effective on or before 01/24/2013 display with a Revision HistoryNumber of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as aseparate and distinct row.

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Related Local Coverage Documents N/A

Related National Coverage Documents N/A

Public Version(s) Updated on 08/05/2015 with effective dates 10/01/2015 - N/A Updated on 07/01/2015 witheffective dates 10/01/2015 - N/A Updated on 03/06/2015 with effective dates 10/01/2015 - N/A Updated on12/02/2014 with effective dates 10/01/2015 - N/A Updated on 08/04/2014 with effective dates 10/01/2015 - N/AUpdated on 06/05/2014 with effective dates 10/01/2015 - N/A Updated on 04/02/2014 with effective dates10/01/2015 - N/A Back to Top


https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35081&ContrId=338&ver=20&ContrVer=1&Date=08%2f13%2f2015&DocID=L35081&kq=1863349065&ua=highwire&displayPDFNote=Y&bc=iAAAAAgACAAAAA%3d%3d&









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