Needle Electromyography Through a Tattoo

This morning I found an interesting question in my email: "Is needle EMG through a tattoo contraindicated?" The physician who inquired was concerned about both an increased risk of infection and possible damage to the tattoo.

The AANEM does not address this issue in any of its documents, although Risks in Electrodiagnostic Medicine says, "Insertion of needle electrodes through infected skin or sores is contraindicated." A search in Muscle & Nerve produced no articles that mention tattoos in any context. I located a statement from the American Association of Nurse Anesthetists that discusses the risk of piercing a tattoo for an epidural. Similar information was available at mayoclinic.com. An increased risk of infection has not been documented, although needle insertion of a fresh tattoo is not advised. When possible, it is desireable to avoid piercing any tattoo should a small scar disfigure the image.

If you have experience with EMG through a tattoo or a similar "preexisting condition," please share it using the comments feature.

Paraspinal Mapping Superior to Imaging for Diagnosing Stenosis

A recent JAMA commentary by AANEM member Dr. Andy Haig, notes that while most surgeons use imaging to diagnose stenosis and make surgical recommendations, recent studies have shed doubt on the ability of imaging to confirm a diagnosis of stenosis. In contrast, new data has shown that paraspinal mapping can reliably identify patients with clinical stenosis. Haig says there are three key steps that need to be taken:“Find and treat what is not stenosis, define and treat the effects of stenosis, and treat presumed stenosis without a definitive diagnosis. Failing all of these steps, a positive diagnosis is an important consideration before surgery,” said Haig.

“I hope this commentary can begin a shift in the way some of these topics are considered and researched. Patients don’t present with stenosis; they present with back pain. As physicians, our guidelines should reflect that we diagnose and treat patients who have symptoms that help us make a diagnosis and treatment plan,” Haig concluded.

The commentary written was published in the January 6, 2010, issue of JAMA. The article was co-author by Christy Tomkins, PhD.

Limited Study EMG: 95870

Parenthetical directions below code 95870 refer users to 95860-95864 when reporting a complete study of an extremity(s). It's not always clear what this means. I have heard from some members who want more information regarding what constitutes a complete study versus a limited study, and when to use the limited code in general.

First, the language of the code 95870 is helpful. "Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters." Study of thoracic paraspinal muscles T2-T11 is reported using 95869. Study of cranial nerve supplied muscle(s) is reported with 95867 (unilateral) or 95868 (bilateral). Study of sphincters is reported with 51785-51792. Additiaonlly, oculoelectromyography is reported with 92262. Finally, laryngeal and diaphragm muscles are also not reported using the limited code becasue they have separate codes, 95865 and 95866 respectively.

Second, five muscles have to be examined to report needle EMG study of a limb. CMS provided specific guidance for codes 95860-95864 in its Final Rule for 1998 on page 59090. “To bill these codes, extremity muscles innervated by three nerves (for example, radial ulnar, median, tibial, peroneal, femoral, not sub branches) or four spinal levels must be evaluated, with a minimum of five muscles studied.” Use this standard for all EMG coding as it is now universally accepted.

If EMG testing fails to meet the five muscle standard described above and cannot be reported using a code for other anatomic sites, report limited needle electromyography code 95870. When appropriate, multiple units of 95870 can be reported for limited study of two, three, or four extremities. It may be necessary to add modifier 59 to additional units of 95870 with some payers.

Needle Electrode Expense

Occasionally I am contacted by a member who wants to know if it is possible bill for the needle electrodes that are used to perform EMG. It is incorrect to report this supply separately becasue it is already included int he value of the procedure code.

Some of these people have tried reporting HCPCS supply code A4215: Needle, sterile, any size, each. I suspect that most of the communication I get on this topic comes after a denial when someone tries A4215 for the first time, because people usually ask if they can bill for the needle, then they ask, "What about A4215?" There may be providers who bill separately for needle electrodes without any problems, but it is technically incorrect and could raise issues in the future during an audit or chart review.