Does 96004 require prior authorization?

No, 96004 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 96004?

Medicare facility rate: $106.21. Non-facility rate: $106.21. Work RVU: 2.09.

Verity

`96004`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

2.09

Facility

$106.21

Non-Facility

$106.21

Documentation Required

Development of a differential diagnosis based upon appropriate history and physical examination prior to performing testing — "Development of a differential diagnosis based upon appropriate history and physical examination" (AANEM recommendations cited).
Testing must be medically indicated and performed using appropriate equipment that provides assessment of all parameters of the recorded signals — "The testing is medically indicated" and "It is performed using equipment that provides assessment of all parameters of the recorded signals (equipment designed for screening purposes is not acceptable)" (AANEM minimum standards).
Needle EMG examination must be performed by a physician specially trained in electrodiagnostic (EDX) medicine — "The EMG must be performed by a trained physician" (AANEM).

Key Coverage Criteria

Individuals being evaluated for carpal tunnel syndrome
Nerve conduction studies with or without standard late responses (e.g., F-wave and H-reflex tests) and for neuromuscular junction testing when performed in conjunction with needle electromyography for any of the following known or suspected disorders:
Peripheral neuropathy/polyneuropathy (e.g., inherited, metabolic, traumatic, entrapment syndromes)
Neuromuscular junction disorders (e.g., myasthenia gravis)
Motor neuron disease
Radiculopathy (cervical, thoracic, or lumbosacral)

10 Active Policies

AETNA-CPB-0263 — Gait Analysis and Electrodynogram

AETNA-CPB-0432 — Computerized Motion Diagnostic Imaging

AETNA-CPB-0752 — Obstructive Sleep Apnea in Children

UHC-POL-neurophysiologic-testing — Neurophysiologic Testing and Monitoring

UMR-POL-UMR-neurophysiologic-testing — Neurophysiologic Testing and Monitoring

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Nerve conduction studies should be performed by a trained physician or a trained individual under the direct supervision of a physician — "The test is performed by a physician, or by a trained technician under the direct supervision of a physician" (AANEM).

One physician should supervise and perform all components of the electrodiagnostic exam; data collection should be under the supervision of the electrodiagnostic (EDX) physician — "One physician supervises and performs all components of the exam" and "Collection of the clinical and electrophysiologic data should be entirely under the supervision of the electrodiagnostic (EDX) physician."

NCS and needle EMG should be performed and interpreted in real time onsite, and reporting NCS and EMG results into separate reports is generally inappropriate — "The AANEM's position is that ... there are no contraindications to EMG in patients with lymphedema ..." and "Reporting NCS and EMG results into separate reports is inappropriate and would be an exception to clinical practice"; also "It is in the best interest of individuals, in the majority of situations, for the needle EMG and the NCS examination to be conducted and interpreted on-site in real time."

SUREST-POL-SUREST-neurophysiologic-testing — Neurophysiologic Testing and Monitoring

CIGNA-0315 — Gait Analysis - (0315)

AETNA-CPB-0107 — Chiropractic Services

AETNA-CPB-0112 — Surface Scanning and Macro Electromyography

AETNA-CPB-0294 — Pedobarography

96004