HOW IT WORKS - CERTIFICATION - STUDIES - REIMBURSEMENT
How It Works - Neural-Scan Physiology
Referred pain results in 30% of patients misdirecting doctors away from the source of pain, and physical exams have even less sensitivity. This explains why the Massachusetts General Hospital Handbook of Pain Management states; "In MOST cases (over 50%) of neck and back pain the anatomic and physiologic diagnosis remains unclear."
The mechanism causing this is explained by Guyton's Textbook of Medical Physiology: Over 90% of A-delta fibers reach the sensory cortex allowing exact localization of the source of pain, but C fibers do not reach the cortex. C fibers are so poor at localizing pain that it can seem to be coming from the opposite side. Following injury C fibers continue firing, but A-deltas fibers down-regulate, so localization is poor. Guyton states; "This explains why so many patients have serious difficulty localizing the source of pain."
The Neural-Scan detects down-regulated A-delta function to locate injured nerve(s) with 95% sensitivity. Its patented modulated electrical signal selectively stimulates A-delta fibers. The higher the amplitude causing an action potential is above the normal range the more indicative of pathology. The Neural-Scan potentiometer verifies firing by detecting the amplitude of the action potential. The patient is his own control, so the test is independent of age, gender and population variables. High potentiometer amplitudes have been reported to have a close correlation with high VAS ratings. The Neural-Scan can also test C and A-beta fibers, which is useful when RSD or sympathetically mediated pain syndrome is suspected.
Certification
By virtue of his license and the AMA and Medicare guidelines, any physician can perform and supervise electrodiagnostic examinations. However, we encourage Neural-Scan users to become certified by covering certification cost through the Academy of Sensory Electrodiagnostic Medicine, the diagnostic branch of the American Association of Sensory Medicine, a nationally recognized organization offering CME credit. The AASM board is composed of prominent physicians from various specialties, including past directors of pain management at Johns Hopkins and LSU, and a present director of Pain Management for Kaiser Permanente. On the AASM website you can find a list of one day workshops wherein your nurse become certified and you take a class on analysis interpretation.
Studies
Studies increasingly are being published and presented at scientific meetings. Recently, the Neural-Scan helped researchers detect a relationship between chronic prostatitis and vulvadynia with S1 radiculopathy. (Baddrodoja, Bush et al) See News & Events and Studies.
Reimbursement
Third-Party Payers are obligated to follow the AMA guidelines and coding, since they embody expert opinions. The Neural-Scan spf-NCS conforms to CPT 95904 Code's two components: (1) Electrical stimulation near a sensory nerve. (2) Measure a component of the action potential at a distant site. Code 95904 only requires one response measurement. Neural-Scan measures the stimulus and action potential amplitudes. Velocity is not required and not measured since detection of pain fiber pathology is not dependent on myelin loss.
Medicare does not designate coverage by brand name, only by procedure. However, in web site online policies Medicare contractors named the Neural-Scan as reimbursable by pointing how the Neural-Scan's potentiometer, which objectively detects threshold firing, makes it different from non-reimbursed psychophysiologic tests wherein patients report feeling a sensation - perception threshold tests. Besides naming the Neural-Scan they exactly describe the Neural-Scan procedure as being reimbursable: "Nerve conduction testing limited to use as an adjunct to physical examination for the initial identification of the presence of peripheral neuropathy, accomplished with devices that use fixed anatomic templates and computer-generated reports, is covered." Though this limits testing to initial examinations, it does not exclude testing necessitated by changing or new symptoms. To avoid confusion between the non-reimbursed perception procedure and objective tests like the Neural-Scan, Medicare in its National Coverage Determination (NCD) Memo CAG00106-R (July 2003) used the titles "Sensory Nerve Conduction Threshold using Current Perception Threshold" in the sections dealing with the non-covered perception tests. The term Sensory Nerve Conduction Threshold (sNCT) appears because it is trademarked by a non-reimbursed device using the term synonymous with Current Perception Threshold. Some online polices abbreviate and only use Sensory Nerve Conduction Threshold, leaving off using Current Perception Threshold, which can cause confusion unless one is aware of Medicare's wording. It should be noted that in CAG00106-R Memo Medicare describes the reimbursable 95904 procedure using the same AMA descriptor components (1) and (2) shown in the above paragraph. CMS confirmed that sNCT is a perception test in CMS 160.23 Sensory Nerve Conduction Threshold Testing (sNCT) (Effective April 1, 2004) (Rev.15, 06-18-04) A.General – "The sNCT is a psychophysical assessment of both central and peripheral nerve function." In no possible way can the use of a potentiometer to objectively measure the action potential be interpreted as a subjective perception (psychophysiological) test.
Online policies concerning electrodiagnosis can be confusing, and not taken at face value. For example, some claim to be restricted to using abbreviated descriptors, and refer providers to consult their AMA CPT Codebook for the full descriptors. However, the AMA CPT Codebook also uses abbreviated descriptors. Full descriptors are only found in the April 2002 AMA EDX Guidelines. Another example is the term NCS (Nerve Conduction Study). This generic term includes all nerve conduction electrodiagnostic exams; EMG (95900), NCV (Nerve Conduction Velocity 95903), and Sensory NCS (95904). Therefore, when NCS appears under a Neuromuscular heading it is understood to be dealing with motor nerve tests (NCS 95900 or 95903), not sensory NCS (95904). If Sensory NCS does specifically appear under a Neuromuscular heading it is in reference to rare situations where the patient has both motor and sensory symptoms. Obviously an EMG should be considered in a patient with motor deficit, but 98% of patient have only sensory symptom without any sign of motor pathology. In such cases an EMG is unnecessary.
Confusion Between Tests
QST: The Neural-Scan is not a QST. QST use stimuli innate to humans, such as hot, cold or pressure and requires the patient to make a judgment of the stimulus intensity; hotter, colder, etc. Humans have no innate ability to accurately judge the intensity of an electrical stimulus and the Neural-Scan does not require the patient to judge the intensity of the electrical signal.
Handheld Device: In this age of miniaturization this seems a rather silly reason for non-reimbursement. However, that said, the Neural-Scan is not a handheld device and not affected by this limitation.
Remote Analysis: The Neural-Scan analysis is performed by the supervising physician and is not performed remotely.
A Word To The Wise: Procedures not specifically listed in the Exclusions of the Patient's Policy are covered, because provisions and exclusions in the patient's policy take precedent over online policies. If an insurer has a blanket non-coverage for a procedure, but does not list this procedure in the exclusions of the policy sold to the patient, then the policy was fraudulently sold and is likely a violation of the RICO ACT covering criminal racketeering.
Last, asking if a Neural-Scan test or Siemens EMG is covered can only result in your being told it is unlisted. No code is by brand name, only by procedure. Code 95904 for over 60 years has been described as: (1) Electrical stimulation near a sensory nerve. (2) Measuring a component of the action potential at a distant site.
Localizing Injury Site
In the spinal cord A-delta fibers synapse with ventral motor nerves, so fire generates voltage directly from the A-delta fibers and sub-threshold voltage from the motor fibers. In minutes a nurse can test all the major nerves in a region - 18 (9 bilateral) in the cervical and 14 (7 bilateral) in the lumbar region - and the nerve(s) requiring the highest voltage to fire identifies the injured nerve(s). The patient is his own control, independent of age, gender or population variables. Once the injured nerve is identified, testing proximal and distal to a suspected site of injury easily verifies the location.
For example; testing above and below the medial elbow detects cubital tunnel entrapment. Comparing median nerve branches in the fingers with the radial nerve (back of the hand) allows differentiation between carpal tunnel entrapment and nerve root pathology since the median and radial nerves originate from the same nerve roots, C6-7. The palmar branches of the median and ulnar nerve pass over the wrist, not through the carpal tunnel or Guyan's canal respectively, so palmar sites differentiate between proximal and wrist entrapments. The same differentiation is at works in the lower extremity where, like the cervical study, all the lumbosacral sites are proximal to sites of entrapment in the ankle. Any branch of a cutaneous nerve can be tested to map the dysfunctional area.
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