Common Indicators Suggesting Fraud & Abuse in Electrodiagnostic Medicine
The American Association of Neuromuscular & Electrodiagnostic Medicine is dedicated to working with payers, providers and law enforcement to put an end to fraudulent and abusive electrodiagnostic (EDX) practices. Unfortunately, over the past decade, there has been a surge in fraudulent and abusive EDX practices – especially with nerve conduction studies (NCSs). The result has been a significant rise in the number of claims – many of which consist of improper testing, erroneous results, and inaccurate diagnoses. This has unnecessarily driven up medical expenses and threatened patient safety.
In an effort to help stem the tide of fraud and abuse in EDX medicine, AANEM has compiled a list of potential
red flags that may
indicate a provider is committing EDX fraud or abuse:
- NCSs are not performed and reviewed at the same time and in the same place as the test (as per CPT coding regulations). See AANEM’s position statement “What Does ‘On Site’ and ‘Real Time’ Mean?”
- The EDX report is not prepared at the same time and in the same place as when/where the studies are performed. (as per CPT coding regulations). See AANEM’s position statement "What Does ‘On Site’ and ‘Real Time’ Mean?"
- Any EDX studies not performed and/or interpreted by a physician that has completed Neurology or Physical Medicine & Rehabilitation residency program. See AANEM’s position statement "Who is Qualified to Practice Electrodiagnostic Medicine?"
- Frequent use (>50%) of CPT codes 95912 (11-12 NCSs) and/or 95913 (13+ NCSs). These codes are rarely indicated for routine EDX studies. Exception: a tertiary academic center that routinely deals with medically complex cases.
- EDX studies performed on the same patient over multiple days. Exception: splitting of a four extremity EDX study into a bilateral upper-extremity day and a bilateral lower-extremity day.
- Use of questionable devices. See AANEM’s Technology Literature Reviews and “Electrodiagnostic Study Instrument Design Requirements” position statement for more details.
- NCSs performed without an accompanying electromyography (EMG). However, it is considered acceptable to only perform an NCS for suspected Carpal Tunnel Syndrome (CTS). Aside from CTS, performing NCSs without an EMG more than 20% of the time is an indicator of possible fraud or abuse.
- Repeat EDX studies for “monitoring” of a condition or diagnosis (e.g., diabetic polyneuropathy). See pages 15-16 of AANEM’s position statement “Recommended Policy for Electrodiagnostic Medicine” for more details.
- Frequent billing of CPT code 95937 (Neuromuscular Junction Testing or Repetitive Stimulation) or billing more than three units of 95937 on a single patient. According to AANEM’s Maximum Number of Studies Table (found on page 6 of AANEM’s “Model Policy for Needle Electromyography and Nerve Conduction Studies”), repetitive stimulation is indicated in cases suspicious for neuromuscular junction (NMJ) disorders (i.e. myasthenia gravis and Lambert-Eaton syndrome) or amyotrophic lateral sclerosis (ALS). These studies are rarely needed unless the physician specializes in NMJ disorders (most likely in an academic setting).
- Surface EMG billed as a needle EMG (often disguised to look like a needle study).
- NCS being duplicated or manipulated for multiple billing opportunities.
- Professional and technical components billed separately. Exception: when an outside physician contracts with a hospital to staff its EDX clinic, the hospital typically bills the technical component while the physician bills the professional component.
- Location of EDX services not in the same office/location as billing provider. Exception: when an outside physician contracts with a hospital to staff its EDX clinic, the hospital typically bills the technical component while the physician bills the professional component.
- Excessive diagnosis of radiculopathy, including multi-level and bilateral radiculopathies. One oft-cited research article documents that EMG confirmed radiculopathy may occur as frequently as 8% in the cervical spine, and 12% in the lumbar spine1. Additionally, most cervical radiculopathies (70-88%) involve only one level2. A significant departure from these expected frequencies of radiculopathy, as confirmed in the medical literature, including multi-level and bilateral radiculopathies, may be an indicator of fraud. Exception: a tertiary academic center that routinely deals with medically complex cases.
This document does not provide an exhaustive list of red flags. Furthermore, the presence of one or more of the examples provided does not necessarily constitute fraud or abuse. It is recommended that a detailed review of questionable EDX studies be performed by an expert in EDX medicine.
Approved by the American Association of Neuromuscular & Electrodiagnostic Medicine: July 2015. Updated and re-approved: December 2020.
1 Braddom RL, Spitz L, Rivner MH. Frequency of Radiculopathies in Motor Vehicle Accidents. Muscle & Nerve 2009; 39:545-547. 2 Dumitru, Electrodiagnostic Medicine. 1st Ed., Hanley and Belfus, Philadelphia, 1995, p. 557