EMG/NCS still viable?

[bubblesdo]

Have heard from a variety of sources online that EMG/NCS are not viable or worth it to do in an outpatient practice due to declining reimbursement. However, when I look at average wrvu rate and wrvu's produced from even a basic study, these definitely seem worth it. From my math, two UE EMG/NCS an hour, which seems quite doable, would be over $400 per hour or approx 8 wrvu/hour and roughly $60/wrvu. This is based on 99203, 95909, and 95886 cpt codes. I'm currently a resident so please tell me where am I wrong if you have insight into this. TIA.

---

Members don't see this ad.

 

[RangerBob]

Have heard from a variety of sources online that EMG/NCS are not viable or worth it to do in an outpatient practice due to declining reimbursement. However, when I look at average wrvu rate and wrvu's produced from even a basic study, these definitely seem worth it. From my math, two UE EMG/NCS an hour, which seems quite doable, would be over $400 per hour or approx 8 wrvu/hour and roughly $60/wrvu. This is based on 99203, 95909, and 95886 cpt codes. I'm currently a resident so please tell me where am I wrong if you have insight into this. TIA.

I don't do EMGs, so I can't comment on the specifics here.

But I can say that anytime reimbursement gets cut (EMG/NCS saw substantial cuts years ago--I think it was almost 50%?), the docs who were used to doing that work for a certain amount of money are going to start saying it's not worth it anymore. This is true of any procedure/surgery that gets targeted for cuts.

Lets take your example. If you really can make $400/hr doing EMGs (seems excessive to me), then doing that 8hrs/day, 40hrs/week, 46 weeks/year (assume 6w vacation, which is more than most docs take), you'd make over $700k!

But at $200, you make a measly $368k. Most of us would say that's great income for 40hrs/week and six weeks off per year, but if you spent 10 years at the higher level of income, you may feel it's not worth it anymore.

I guess that example likely proves $400/hr is not happening, as there are lots of physiatrists running EMG mills but to my knowledge most make far less than $700k. If they are making that, then that's not taking business expenses into account.

I subscribe to the "plenty of money and relaxation" philosophy of PM&R--do enough to make enough, but have enough free time. Your biggest risks of losing your income in medicine are divorce and burnout. So find a good spouse, spend time with them, and work to make "enough" to live on.

 

[operaman]

Have heard from a variety of sources online that EMG/NCS are not viable or worth it to do in an outpatient practice due to declining reimbursement. However, when I look at average wrvu rate and wrvu's produced from even a basic study, these definitely seem worth it. From my math, two UE EMG/NCS an hour, which seems quite doable, would be over $400 per hour or approx 8 wrvu/hour and roughly $60/wrvu. This is based on 99203, 95909, and 95886 cpt codes. I'm currently a resident so please tell me where am I wrong if you have insight into this. TIA.

You would have to be very careful with your documentation if you plan to bill an E&M code (99203) same day as procedure codes (the others). This is a commonly audited issue in medicine because in theory the Emg/ncs codes (any procedure code) already include the periprocedural H&P.

So if you have a super high volume emg/ncs thing going, odds are good that you’re basically just doing the procedures. It’s like a GI doc just banging out screening colonoscopies - he’s likely just billing the procedure codes. His midlevel or him on a different day probably billed a new patient E&M back in the office.

The way to bill all of it is people are referred to you for something and you perform an E&M service during which, based on your findings, decided to perform EMG/NCS studies that same day. Or they came for EMG but also raised a separate issue. Then you could append a -25 modifier to the 99203, but you’ve gotta be sure your documentation supports it.

If you’re just banging out studies and sending reports to referring docs but not personally managing the condition, it’s probably going to be hard to justify the E&M code in an audit. If you are evaluating and managing in addition to performing the studies, it may be hard to be so fast and efficient to get the volumes you’d need for the $400 /hr.

 

[JBM16BYU]

I’m biased (PM&R/Neuromuscular) but from a supply and demand perspective, EMG/NCS is definitely needed/wanted. Our EMG lab is constantly full due to the demand for the procedure. In addition, there’s a reason that many PM&R, even if they do a sports medicine or pain fellowship, are asked by certain practices if they can perform EMG/NCS as well.

PM&R is uniquely set up, as a specialty, to really dominate in this space. With the current requirement of 200 EMGs during residency, it gives you a great enough exposure that you should be able to do basic EMGs (carpal tunnel, ulnar neuropathy, radiculopathies, polyneuropathy) and know when something doesn’t fall into this standard realm and when to refer on to an academic center. Neurology residencies currently do not have the requirement, so many (if not all) neurologists who perform EMG routinely in practice only do so after completing neuromuscular or clinical neurophysiology fellowships. That said, there are rumors and whispers of the 200 requirement changing for PM&R, which I personally think would be a disservice to residents training and disservice to patients seen by those who are not as fully qualified to perform the examination. EMG, like any procedure, takes time and countless independent performance in order to master.

 

[voodoomedic]

But I can say that anytime reimbursement gets cut (EMG/NCS saw substantial cuts years ago--I think it was almost 50%?), the docs who were used to doing that work for a certain amount of money are going to start saying it's not worth it anymore. This is true of any procedure/surgery that gets targeted for cuts.

It was almost exactly a 50% cut. Up until then I was shoehorning a couple dozen BUE EMG/NVCs a month between regular MSK and interventional pain evals. When the cuts were made, it made more sense to fill those slots with spine/pain patients. It is still a money maker if you have volume AND you're quick. You can do a solid BUE exam in 15min once you're rolling with your software, I assure you. That being said, best bet if you really want to maximize your clinic time AND have enough volume to justify it, is to hire a tech to do the NCV portion, and you pop in for the needle, sum up results, and make a plan for treatment. This is best done in a setting where your partners (esp NSG) are feeding you constantly.

 

[voodoomedic]

PM&R is uniquely set up, as a specialty, to really dominate in this space. With the current requirement of 200 EMGs during residency, it gives you a great enough exposure that you should be able to do basic EMGs (carpal tunnel, ulnar neuropathy, radiculopathies, polyneuropathy) and know when something doesn’t fall into this standard realm and when to refer on to an academic center. Neurology residencies currently do not have the requirement, so many (if not all) neurologists who perform EMG routinely in practice only do so after completing neuromuscular or clinical neurophysiology fellowships.

It is stunning to see how absolutely terrible the EMGs are from some Neurologists, even in major urban areas. There is a clear deficiency in their training in an area which PM&R excels in. When I stopped doing them and started farming them out to Neuro, it became painfully clear that I'd have to do my own interpretations/overreads of their data. Our group has a running snark that "if you want to find a guaranteed radiculopathy, send it to Neurology." Mind you, most of them are spine surgeons so for them, its ideal, even if it's not ideal for the patients.

"2+ fibs and sharps seen in cervical paraspinals, deltoid, biceps, triceps, PT, FDI, and APB consistent with C4-C8 radiculopathy" was clearly in their template dropdown menu. Oh, and they NEVER include snapshots of said EMG abnormalites......sorry, small rant.

 

[runfastnow]

I do EMG/NCS for small ortho group. 5-8 per week radic screens, carpal/cubital tunnel, etc. Any ALS, MG, myopathy stuff gets sent to academic center for confirmation.

You do have to be careful with billing E&M for the patients same day. I typically only bill E&M if it is my patient and we are also discussing other management issues outside the EMG/NCS and/or starting meds.

Payment may not be as great as the 2000-10s but if you can do efficient carpal tunnel screens (3ish per hour) can be a nice living or excellent complement within a multi-specialty group.

 

[fozzy40]

It's viable but you have to keep yourself marketable. PT's have really creeped into this space. See the following link. I am not insurance based and set my own cash prices for these studies. Ortho groups that previously referred all their patients to me started referring to a PT in the area that does these studies. The PT is charging low prices per study in exchange for volume and billing. Ortho went with the cheaper option. I've read their studies and they aren't horrible technicians. However, test design and interpretation is really lacking. The problem is that both the PTs and the surgeons think they know what good is but they don't.

So keeping yourself marketable is always the priority despite the reimbursement!

 

[sloh]

It's viable but you have to keep yourself marketable. PT's have really creeped into this space. See the following link. I am not insurance based and set my own cash prices for these studies. Ortho groups that previously referred all their patients to me started referring to a PT in the area that does these studies. The PT is charging low prices per study in exchange for volume and billing. Ortho went with the cheaper option. I've read their studies and they aren't horrible technicians. However, test design and interpretation is really lacking. The problem is that both the PTs and the surgeons think they know what good is but they don't.

So keeping yourself marketable is always the priority despite the reimbursement!

Haha but interpretation is like most of it. How do you even know what to stick without being great at interpretation? This is sad.

 

[Smooglabish]

I don't understand how PTs are doing EMG/NCS.

Are they acting as technicians without providing diagnosis and interpretation?

I think EMG is still quite viable as many surgeons want EDX reports justifying their surgical plans. Beyond that, sometimes the EMG result itself will guide the ddx in a new direction that isn't as clinically obvious.

 

[fozzy40]

Haha but interpretation is like most of it. How do you even know what to stick without being great at interpretation? This is sad.

Go by protocol. PTs know enough in terms of muscle/nerve innervation

 

[fozzy40]

Haha but interpretation is like most of it. How do you even know what to stick without being great at interpretation? This is sad.

I don't understand how PTs are doing EMG/NCS.

Are they acting as technicians without providing diagnosis and interpretation?

I think EMG is still quite viable as many surgeons want EDX reports justifying their surgical plans. Beyond that, sometimes the EMG result itself will guide the ddx in a new direction that isn't as clinically obvious.

Very common particularly in the military. PTs are technically proficient with time. One PT in my error is pretty good with 20+ years of clinical experience for basic ortho stuff. However they don’t have the clinical experience to go along with it.

 

[sdnuser001]

It's def viable I do sometimes as many as 16 on my EMG days and always bill an E&M consult with it. I work in a multispecialty ortho group. This was common practice and encouraged when I was in fellowship and makes perfect sense since you also need to talk to the patient and do an exam in order to determine what nerves to test. Not to mention reviewing the chart, looking at the images, etc.

I do 2-3 studies an hour and typically get $600 for a complete study + E&M consult. You can do the math, but on a busy EMG day I often collect nearly as much as my injection days.

 

[sloh]

It's def viable I do sometimes as many as 16 on my EMG days and always bill an E&M consult with it. I work in a multispecialty ortho group. This was common practice and encouraged when I was in fellowship and makes perfect sense since you also need to talk to the patient and do an exam in order to determine what nerves to test. Not to mention reviewing the chart, looking at the images, etc.

I do 2-3 studies an hour and typically get $600 for a complete study + E&M consult. You can do the math, but on a busy EMG day I often collect nearly as much as my injection days.

Impressive! 600/hr

 

[SSdoc33]

the key is the e/m. those 99204's add up