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Local and Focused Medical Review Policies

Analysis of January through June 1996 claims data indicated that Anal or Urethral Sphincter e1ectromyography (EMG) (procedure codes 51784 and 51785) has been billed substantially more in Florida than at the national level for specialty 34 (Urology). These codes were selected for 1997 Focused Medical Review (FMR). As a result of this aberrancy, a local medical review policy was developed to establish the conditions/illnesses for which Medicare Part B of Florida will consider the service to be medically reasonab1e and necessary. This policy includes procedure codes 51784 (Electromyography of anal or urethral sphincter, other than needle, any technique, and 51785 (Needle e1ectromyography studies of anal or urethral sphincter, any technique). This policy is effective for services processed on or after February 16^th 1998.

The reason why Florida has so many claims for 51784 is (1) that Florida has so many elderly people who are incontinent, and (2) the prevalence of large incontinent populations has led several corporations to set up Continence Clinics with multiple locations. These groups have simply followed their equipment manufacturers’ recommendations for billing 51784 when conducting an EMG evaluation of the sphincters.

Electromyography (EMG) of the anal or urethral sphincter is a urodynamic study that assesses the neuromuscular function of the external sphincter and assesses the functional balance between the bladder and striated sphincter muscle activity.

Unfortunately, the use of EMG in urodynamics is only one form of EMG of the sphincters, albeit historically the earliest form. The discussion which follows is accurate for urodynamics, but it does not encompass the whole EMG field anymore.

EMG alone gives useful information about sphincteric function, but it is most valuable when done in conjunction with cystometry to determine whether the striated sphincter appropriate increases its activity in a gradual fashion during bladder filling and whether rest occurs normally before and during bladder contraction. According to a vast majority of urologists, the study of the activity of one group of muscles (in this case, the striated musculature of the outlet) with respect to another (in this case, bladder) is termed Kinesiologic electromyography. Kinesiologic EMG can be performed with either needle electrodes or surface or patch electrodes. Surface electrode recordings can be obtained either from the lumen of the urethra in the region of the voluntary sphincter or, preferably, from the anal sphincter by using an anal plug electrode.

This discussion overlooks the existence of vaginal and anal EMG sensors, which are relatively new but far more effective than the old "anal plug" electrodes. Anal plugs, originally developed for electrical stimulation of the EAS, have circular electrodes. Since 1976 a new style anal or vaginal EMG sensor has been available that contains longitudinal electrodes. Since EMG evaluation of a muscle depends on the physical relationship between the electrodes and the body of the muscle in question, the distinction is extremely important for accurate readings.

A study by N. R. Binnie et al ("The importance of the orientation of the electrode plates in recording external anal sphincter EMG by non-invasive anal plug electrodes", Int. J. of Colorectal Disease, 1991, 6:5, 8-11) compared sensors with circular electrodes and sensors with longitudinal electrodes to traditional needle electrodes, and found that the longitudinal electrodes (only) corrolated with needle electrodes at rest (r=0.99, p.<0.01), during voluntary squeeze (r=0.99, p.<0.001) and with strain (r=0.91, p. <0.01). The longitudinal electrodes were more sensitive than circular ones by a factor of 10. [Specifically, circular electrodes produced less output, and were incapable of detecting weak contractions.]

In addition, the most popular brand of vaginal EMG sensors has the two active longitudinal electrodes located 120 degrees apart, so these sensors are more sensitive to EMG signals originating on the urethral side of the vaginal vault.

Recording via needle electrodes can be obtained from the anal sphincter, from the bulk of the musculature of the pelvic floor, or from the external sphincter itself, though in the latter case the placement is difficult and the accuracy of the results questionable.

Direct needle EMG of the urethral sphincter provides the most accurate information. However, the technique is difficult, therefore simpler approaches are generally used. The anal sphincter is readily accessible for EMG testing and testing of any area of the pelvic floor musculature generally reflects the overall electrical activity of the pelvic floor, including the external sphincter.

Actually, while the first part is true, it is now known that the External Anal Sphincter often operates quite independently of the pelvic floor itself. Jeannette Tries has demonstrated this frequently in her research with her new "Multi-Electrode Probe" (MEP), being advertised by SRS Medical Systems, Inc. [Most recently at the National Multi-Specialty Nursing Conference on Urinary Incontinence, Orlando, Florida, January 18, 1998.]

Another type of electromyography that involves the study of the bioelectric potentials generated by skeletal muscle is called a Motor unit EMG. Motor unit EMG is a very accurate way of detecting evidence of denervation or myopathy in the striated pelvic floor musculature. This procedure must be performed using the needle electrodes and requires the performer of the service to have considerable experience with interpreting the various parameters recorded during a Motor unit EMG, and, therefore is normally performed by a neurologist.

Still another type of electomyography – surface electromyography of skeletal muscles – has been completely overlooked in this summary. The earliest use of sEMG was in relaxation training for tension-related conditions, and chronic muscle tension pain, especially related to the spine. According to John V. Basmajian, about 1,000 clinicians use this technique in the US (Futurehealth’s Key West EMG Conference, Feb., 1996)

But at least 2,000 clinicians use sEMG in conjunction with vaginal and/or anal EMG sensors to treat urinary (and fecal) incontinence, especially but not exclusively, in the elderly. This new therapy has been in use since 1978, but became popular as a result of an NIA Consensus Development Conference in 1988. It was established as part of the first line of treatment for urinary incontinence in adults by the 1992 Guideline report from the Agency for Health Care Policy and Research, part of the Public Health Service. In 1996 the AHCPR revised and strengthened its recommendations favoring the behavioral interventions in general and biofeedback in particular. According to the AHCPR, the evidence in support of this application of EMG biofeedback is rated "A" – the highest possible rating.]

Given this history, it is difficult to understand how the Florida Medicare reviewers could have failed to include it as one of the "types" of EMG in use in the medical world.

Currently the International Continence Society doesn’t specify normal findings for sphincter EMG. However, the EMG should show increased muscle activity when the patient tightens the external urinary sphincter and decreased muscle activity when he relaxes it.

Although the ICS doesn’t specify norms, the professional literature contains hundreds of references to the normal findings for sphincter EMG values. Thanks to computerized EMG systems, it is now possible to obtain significantly more detailed information about the condition of urinary and anal sphincter muscle activity. Rather than simply reporting "increased" and "decreased" EMG values, as is done in urodynamics, it is now possible to specify exact EMG levels in microvolts. Ample research has shown that the strength of the sphincter muscles reflects their ability to prevent urinary (and fecal) leakage.

In addition to analysis of the EMG amplitude, current research and recent publications focus on frequency spectrum analysis. As a muscle fatigues, the median frequency of the EMG signal drops. One advantage of this new technique is that it is possible to determine the point of physiological fatigue, so that exercise regimes can be personalized for maximum effectiveness.

If EMG and cystometrography are done together, results show that muscle activity of the normal sphincter increases as the bladder fills. During voiding and with bladder contraction, muscle activity decreases as the sphincter relaxes. This comparison aids assessment of external sphincter efficiency and the functional balance between bladder and sphincter muscle activity.

In addition, with sEMG from vaginal or anal sensors, it is possible determine from week to week the relative strength of the pelvic muscles with great precision. This is essential to evaluate the patient’s progress in any biofeedback program for rehabilitation of the muscles. One specific use of this information is to determine if, for example, a few days without urinary (or fecal) accidents is a result of corresponding improvements in sphincter condition, or simply a random finding.

An abnormal EMG results from: (1) the failure of the sphincter to relax; or (2) increased muscle activity during voiding demonstrates detrusor-external sphincter dyssynergia. Confirmation of such muscle activity by EMG may indicate neurogenic bladder, spinal cord injury, multiple sclerosis, Parkinson’s disease, or stress incontinence.

While the preceding is true of the crude "raw EMG signals" used in urodynamic evaluations, considerably more information from the integrated EMG signals processed by modern psychophysiological monitoring instruments (which are used in both "evaluation" and "biofeedback" modes). For example, a 10-second score of, say, 4.5 microvolts on two successive weeks indicates a lack of improvement, and therefore, the necessity to make adjustments in the patient’s biofeedback program.

The elements of a standard EMG evaluation, currently billed under 51784, are described in detail in a document available on the Incontinence on the Internet website at: <http://www.incontinet.com/emgeval.htm>.

Medicare Part B will consider an anal or urethral electromyogram medically reasonable and necessary as a diagnostic test for the initial evaluation of patients with a voiding dysfunction such as urinary incontinence, neuropathic disorder, etc. If the cause of the patient’s disorder cannot be determined after clinical evaluation (history and physical). In addition, it is expected that other urodynamic testing consisting of cystometry, urethral profilometry, and uroflowmetry are performed with an EMG.

Once a diagnosis of voiding dysfunction has been confirmed or ruled out, it is not considered necessary to repeat the test unless the patient presents with new symptomatology suggestive of a voiding dysfunction and the cause cannot be determined by clinical evaluation.

Coding Guidelines

When EMG is performed as a part of a biofeedback session, CPT codes 51784 or 51785 is not to be billed unless a significant, separately identifiable diagnostic service is provided. If the CPT code 51784 or 51785 is to be used for a diagnostic EMG, a separate report must be available in the medical records to indicate this service was performed.

This paragraph does not appear to rule out the use of a separate EMG evaluation, billed under 51784, provided that an appropriate and separate report is included in the medical records.

Biofeedback therapy differs from EMG, which is a diagnostic procedure used to record and study the electrical properties of skeletal muscle. An EMG device may be used to provide feedback with certain types of biofeedback. Biofeedback (anorectal) performed for fecal incontinence includes an EMG, and therefore, should be billed utilizing procedure code 90911.

This paragraph, although crucial, is ensnarled in confusing syntax. It is factually incorrect to say that "Biofeedback (anorectal) performed for fecal incontinence includes an EMG…". For example, biofeedback provided by either large-balloon manometrics [e.g., Burgio’s work], or specialized manometric biofeedback devices [e.g., home trainers form InCare and Biosearch] have no EMG component whatsoever!

Both procedure code 51784/51785 and 90911 should not be billed together when only biofeedback training is being performed.

We cannot rule out the possibility that some unscrupulous clinicians have actually been committing fraud by billing for both an EMG evaluation and a biofeedback training session, when in fact only a simple biofeedback session was held; this may be the real "target" of the revised regulations.

Under The Perry Protocol, a muscle evaluation (billed as 51784) is normally conducted each week to determine if additional pelvic muscle exercise (billed as 90911) is indicated. Most computerized EMG biofeedback systems print separate reports, one for the evaluation and one for the training activities. Although sold as a package, the two components are usually separate computer programs.

Medical record documentation should demonstrate that the patient had signs and symptoms of a voiding dysfunction and the cause cannot be determined after clinical evaluation. In addition, documentation of the service that was performed including the results of the EMG should be available. This information is normally found in the office notes, progress notes, history and physical, and the hard copy test results.

If the provider of the service is other than the ordering/referring physician, the provider must maintain hard copy documentation of test result(s) and interpretation, along with copies of the ordering/referring physician’s order for the test(s). The physician must state the clinical indication/medical necessity for the study in his order for the test.

Draft Revised: Wednesday, May 04, 2005 12:29:08 AM

For the latest version of this document, visit  <http://www.incontinet.com/flmed.htm>

Copyright 1998 by Incontinet