Unqualified Electrodiagnostic practitioners

Update 11/05:  Nerve conduction studies in the Medicare Part B Newsletter:

MEDICARE PART B NEWSLETTER
July 1, 2005, 05-054

FROM THE DESK OF THE CONTRACTOR MEDICAL DIRECTORS… NERVE CONDUCTION STUDIES
DC/DE, MD, TX, VA, IHS Service Areas

"Nerve conduction studies must provide, in real-time, a number of response parameters. Those parameters include amplitude, latency, configuration and sensory conduction velocity. A major component of this electrodiagnostic examination is the history and physical and the interaction between the provider performing the study and the patient, allowing for real-time provider interpretation.Medicare does not accept diagnostic studies that do not provide the information described above, nor does it accept diagnostic studies that provide delayed interpretation as substitutes for nerve conduction studies. Electromyographic studies that are performed with surface electrodes instead of needle technology, and nerve conduction studies that do not provide real-time conduction, amplitude, and latency/velocity data should not be billed with the standard electrodiagnostic codes (i.e., 95860 for EMG or 95900 for nerve conduction studies). Instead, they should be billed with the Not Otherwise Classified (NOC) code, 95999. A description of the procedure, indicating use of surface electrodes for EMG studies (use words: surface electrodes, and the words: transtelephonic and /or delayed interpretation for nerve conduction studies) should be included in Item 19 of the CMS-1500 form. For electronic billing, the description should be included in the comment field." FROM THE DESK OF THE CONTRACTOR MEDICAL DIRECTORS… NERVE CONDUCTION STUDIES
DC/DE, MD, TX, VA, IHS Service Areas

end quote from Medicare Newsletter

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Neurologist Concerns:

Neurologists have been increasingly concerned about unqualified "practitioners" of nerve conduction studies and EMG.  Many examples of this take place in Virginia including studies sent via modem to distant physicians who are in no position to properly supervise the electrodiagnostic exam. 

Unqualified persons acting as NCV/EMG technologists have been performing studies without adequate training and supervision.  Patients suffer misdiagnosis and inappropriate treatment or surgery when this occurs.  It is the responsibility of neurologist to report such cases to the AANEM (American Association of Neuromuscular and Electrodiagnostic Medicine).

This is a national problem and it is discussed in other state societies' web pages.

Please see the AANEM position statement regarding training necessary to perform electrodiagnostic medicine.

If the society can be of help to any neurologist who is aware of any such practices please contact Dr. Blair Marsteller ( blairm1@cox.net ).

THE CASE OF J. DOE:  ACTUAL CASE

These Acrobat files are of the patient J. Doe who had a first NCV in 9/03 done at a surgical practice where no trained electrodiagnostic personnel work.  Identifying patient data and the trade name of the system used is removed.  The study was repeated 20 months later in a good quality EMG lab, the study from which is below.   On the basis of the first study J. Doe had bilateral CTS surgery.   She was sent to the second EMG lab by her primary MD when she reported ongoing symptoms.

First Study: Sept. 2003

Second Study: May 2005

The quality of the first study is poor.  There is no resolution of the median nerve compound motor action potential on either side (despite the latency measurements noted).  The ulnar motor response is of low amplitude but was probably submaximally stimulated by the untrained tester.  No sensory values are collected.  Motor conduction velocities are not done since there were no proximal motor stimuli.   Curiously, there are numerous F-wave latencies preformed, something of limited value in a suspected case of median neuropathy at the wrist.

The second study is of high quality and would be in keeping with an electrodiagnostic lab where patients can receive reliable and safe testing.

©2005 Virginia Neurological Society - All rights reserved.

Real cases in VA

CASE #1  A Virginia neurologist has reported that an employee of his did electrodiagnostic studies for a previous employer who is an MD (untrained in electrodiagnostic medicine).  She had a high school education and barely 5 weeks of electrodiagnostic training.  After this brief training period she then performed electrodiagnostic studies totally on her own in the doctor’s office.  The studies were interpreted by a Florida “associate member” of the AANEM.

CASE#2  A Virginia neurologist requested previous records from an MD regarding a patient who had an EMG at that practice.  None of the MDs there are trained in electrodiagnostic medicine.  The "EMG" showed one sweep each of a median motor and ulnar motor NCV.  The amplitudes were so low as to be barely above the baseline.  No proximal stimulations were done and no sensory values were obtained.  The interpreting MD (also in Florida) concluded a confident normal result.

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