1. Rob Rubenstein MD Neurologist - The Doctors Clinic Topic – EMG/NCV Testing

2. Follow up on Botox for Migraine Old code: 64612 and 64613 (modified) New code: 64615

3. EMG/NCV Testing -What it means -Why we do it -How we code it

4. It’s not torture!

5. NCV = Nerve Conduction Velocity It simply determines how fast a nerve transmits it’s electrical signal It assesses the peripheral nerves only – “motor” & “sensory”

6. What it doesn’t do Doesn’t detect central nervous system problems like stroke, Multiple Sclerosis, brain tumors, etc…

7. Common nerve problems evaluated by nerve conduction testing Carpal tunnel syndrome Ulnar, peroneal neuropathy Peripheral neuropathy – e.g. diabetes, alcohol, chemotherapy And some less common disorders – Guillain Barre syndrome, CIDP, ALS,

8. How NCV testing works - I measure the distance between 2 stimulation points, in millimeters, with my $1.95 tape measure - The $20,000 machine measures the time, in milliseconds, it takes the nerve to transmit the signal between the two stimulation points - Voila! Distance/time, like miles/hours, tells the speed (conduction velocity) of the nerves. Nerves travel slower if pinched (at the elbow), compressed (in the Carpal Tunnel), damaged (neuropathies like Guillain-Barre, Diabetes, Alcohol)

9. Correct!

10. Incorrect!

11. Coding Straightforward – it’s based on the total number of nerves examined: 1-2 nerves: 95907 3-4 nerves: 95908 5-6 nerves: 95909 7-8 nerves: 95910 9-10 nerves: 95911 11-12 nerves: 95912

13. EMG = Electromyography

14. Electromyography Doesn’t directly measure the nerves, but instead directly measures the electrical activity of the muscle fibers themselves Useful to detect pinched nerves in the neck or back, muscle diseases like muscular dystrophy or myopathies Will be abnormal if the nerve supplying the muscle examined is severely damaged, like a bad carpal tunnel syndrome, severe neuropathy, sciatica, Lou Gehrig’s disease, etc…

15. Continued: -There are no electric shocks involved - 28-30 gauge needle that’s coated in Teflon, with the last millimeter bare metal. It works a lot like a phonograph needle For many people, the EMG part of the exam is less irritating than the NCV test Can tell if a pinched nerve is new, old, or both

16. No, it’s not torture either!

17. EMG

18. Need to know your muscles!

19. …and the nerves that connect them

20. EMG Coding 2 Determinants: 1. Is an NCV study also performed? 2. Is it a limited study (5 or fewer muscles examined) or not (more than 5 muscles)

21. Done by itself, with no NCV study: -Limited study: 95870 -Full limb: – 1 limb: 95860 – 2 limbs: 95861 – 3 limbs: 95863 – 4 limbs: 95864

22. “Add On” with NCV study: - Limited: 95885 - 1 Extremity: 95886 (modified by the number of limbs examined)

23. Less Common Codes 95887: EMG of a non-extremity add on to NCV - facial muscles in Bell’s Palsy -paraspinal muscles 95874: Guided Nerve Destruction, Needle EMG - used in directing Botox injections for spasticity

25. Bonus Talk The Neurologic Exam - Gait 1. Normal 2. Footdrop 3. Hemi-paretic 4. Parkinsonian – Hemi, Bilateral 5. Hyperkinetic 6. Orthopedic 7. Trendelenberg 8. Vestibular 9. Alcoholic-Cerebellar 10. Senile – anteropulsion/retropulsion 11. Astasia-abasia 12.Romberg