G40.C11 — Lafora progressive myoclonus epilepsy, intractable, with status epilepticus
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When billing CPT 95905 for carpal tunnel, the diagnosis code must be G56.01 or G56.02.
- Data gathered during NCS should be available to support the claim, although it is not necessary to include documentation with every claim submission.
- Providers are expected to use CPT 95870 for sampling muscles other than paraspinals associated with tested extremities; CPT 95870 should not be billed for paraspinal sampling when extremity EMG codes 95860, 95861, 95863, or 95864 are also billed.
- PTs performing the technical portion of needle EMG under the 6A designation must be ABPTS-certified as a qualified electrophysiologic clinical specialist and must be authorized by state law to perform the service.
Key Coverage Criteria
- Automated nerve conduction testing using the NC-stat (CPT 95905) is allowed only when there is a high pre-test or prior probability of carpal tunnel syndrome and the claim uses diagnosis code G56.01 or G56.02; allowed one service per arm.
- If authorized by state law, physical therapists (PTs) are allowed to perform the technical and professional components of nerve conduction studies represented by CPT codes 95907-95913 consistent with a 7A supervision designation (effective 01/01/2013).
- If authorized by state law, the technical component of neuromuscular junction testing CPT 95937 (TC) with supervision designation 7A is allowable for PTs consistent with the 7A description (effective 01/01/2013).
- Needle electromyography CPT codes 95860-95872 and 95885-95887 have a 6A designation for the technical portion; PTs who are ABPTS-certified as qualified electrophysiologic clinical specialists and are authorized by state law may perform the technical and professional components according to the 6A description.
- Electrodiagnostic nerve conduction studies and electromyography that provide real-time response parameters (amplitude, latency, configuration, conduction velocity) are acceptable for Medicare payment and should be used for provider interpretation.
- Electrodiagnostic testing must be performed by healthcare professionals who are appropriately trained and/or credentialed via formal residency/fellowship, national certification, or accredited post-graduate training covering anatomy, neurophysiology, NCS and EMG.
6 Active Policies
AMBETTER-CP.MP.105 — Digital EEG Spike Analysis
CIGNA-0521 — Electroencephalography - (0521)
ANTHEM-CG-MED-76 — CG-MED-76 Magnetic Source Imaging and Magnetoencephalography
ANTHEM-CG-MED-05 — CG-MED-05 Ketogenic Diet for Treatment of Intractable Seizures
A56619 — Billing and Coding: Nerve Conduction Studies and Electromyography
Related Codes
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