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WARNING: THIS IS A TEXAS HEALTH AND HUMAN SERVICES INFORMATION RESOURCES SYSTEM THAT CONTAINS STATE AND/OR U.S. GOVERNMENT INFORMATION. BY USING THIS SYSTEM YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE NO RIGHT OF PRIVACY IN CONNECTION WITH YOUR USE OF THE SYSTEM OR YOUR ACCESS TO THE INFORMATION CONTAINED WITHIN IT. BY ACCESSING AND USING THIS SYSTEM YOU ARE CONSENTING TO THE MONITORING OF YOUR USE OF THE SYSTEM, AND TO SECURITY ASSESSMENT AND AUDITING ACTIVITIES THAT MAY BE USED FOR LAW ENFORCEMENT OR OTHER LEGALLY PERMISSIBLE PURPOSES. ANY UNAUTHORIZED USE OR ACCESS, OR ANY UNAUTHORIZED ATTEMPTS TO USE OR ACCESS, THIS SYSTEM MAY SUBJECT YOU TO DISCIPLINARY ACTION, SANCTIONS, CIVIL PENALTIES, OR CRIMINAL PROSECUTION TO THE EXTENT PERMITTED UNDER APPLICABLE LAW.
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AMA/ADA End User License Agreement
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT® ")

You, your employees and agents are authorized to use CPT only as contained in materials on the Texas Medicaid & Healthcare Partnership (TMHP) website solely for your own personal use in directly participating in healthcare programs administered by THHS. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, 515 N. State Street, Chicago, Illinois, 60610. Applications are available at the American Medical Association website, www.ama-assn.org/go/cpt.

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This product includes CPT which is commercial technical data and/or computer databases and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer databases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

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Evoked Response Tests and Neuromuscular Procedures Benefits to Change for Texas Medicaid January 1, 2023

Last updated on 11/11/2022

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after January 1, 2023, evoked response tests and neuromuscular procedures benefits will change for Texas Medicaid.

Overview of Benefit Changes

Major changes to this medical benefit include the following:

Updates for some electromyography (EMG) and nerve conduction study (NCS) limitations
Additional payable diagnosis codes for some EMG and NCS procedure codes
Payable provider type updates

Limitation Updates

Claims for all evoked response tests and neuromuscular procedures that exceed the allowed number of services per rolling year will be considered for reimbursement on appeal, if that appeal includes documentation supporting the medical necessity.

EMG Procedures

Limitations for the following EMG procedure codes will change:

Procedure Codes	New Limitations
95866	One service per day, by the same provider
95872, 95875	Two services per day, by the same provider

NCS Procedures

NCS procedure codes 95885 and 95886 will be limited to once per extremity up to two units, using any combination of procedure codes, per day, any provider.

Procedure code 95937 is limited to three studies per day, same provider. When the anticipated number of NCSs planned for an evaluation exceeds three studies per day, a prior authorization request must be received on or within 90 days before the requested date of service and must include documentation supporting medical necessity for the number of studies requested.

The requesting provider must sign the Special Medical Prior Authorization (SMPA) Request Form on or within 90 days before the requested start of service. All dates of service that occur before the prescribing provider’s signature date will be denied.

Additional Diagnosis Codes

Diagnosis codes M3500, M3501, M3502, M3503, M3504, and M3509 will be added as payable diagnoses for all EMG and NCS procedure codes.

The following diagnosis codes will be added as payable diagnoses for the EMG and NCS procedure codes listed below:

Diagnosis Codes
D510	D511	D513	D518	D519	D538	E52
E530	E531	E538	E550	E559	E610

EMG and NCS Procedure Codes
95860	95861	95863	95864	95865	95866	95867
95868	95869	95870	95872	95875	95885	95886
95887	95905	95907	95908	95909	95910	95911
95912	95913

Diagnosis codes S4490XA, S4490XD, and S4490XS will be added as payable diagnoses for EMG procedure code 95868.

Diagnosis Codes Currently Covered

Vestibular evoked myogenic potential (VEMP) procedure codes 92517, 92518, and 92519 may be reimbursed when submitted with diagnosis codes H818X1, H818X2, H818X3, or H818X9.

EMG procedure code 95861 may be reimbursed when submitted with diagnosis codes S8410XS, S8410XA, and S8410XD.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.28 “Evoked Response Tests and Neuromuscular Procedures,” for additional currently payable diagnosis codes for VEMP and EMG procedures.

Provider Type Updates

The following additional payable provider types will be added for visual evoked potential testing procedure code 95930:

The total component may be reimbursed to:
- Physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), and radiation therapy center providers for services rendered in the office and outpatient hospital settings.
- PA, NP, and CNS providers for services rendered in the inpatient hospital setting.
The professional component may be reimbursed to:
- PA, NP, and CNS providers for services rendered in inpatient and outpatient hospital settings.

The following additional payable provider types will be added for NCS procedure code 95933:

The total component may be reimbursed to:
- Optometrist and federally qualified health center (FQHC) providers for services rendered in the office setting.
- PA, NP, and CNS providers for services rendered in the inpatient hospital setting.
- PA, NP, CNS, physician, optometrist, radiation therapy center, FQHC, portable X-ray supplier, radiological lab, and physiological lab providers for services rendered in the outpatient hospital setting.
The professional component may be reimbursed to:
- PA, NP, CNS, and optometrist providers for services rendered in the inpatient hospital setting.
- PA, NP, CNS, optometrist, and FQHC providers for services rendered in the outpatient hospital setting.
The technical component may be reimbursed to:
- FQHC providers for services rendered in the office setting.
- PA, NP, CNS, physician, optometrist, FQHC, portable X-ray supplier, radiological lab, and physiological lab providers for services rendered in the outpatient hospital setting.

For more information, call the TMHP Contact Center at 800-925-9126.