needle EMG by non physician

[bedrock]

Question for you all. I recognize that you Ll likely think this is a bad thing but my question isn’t about that but rather the legality of these situations?

Can a non physician bill for a needle EMG?
(I recognize that in many practices, the NCS are done by techs and the needle EMG by a physician and then the physician bills for both)

can some familiar with needle EMG like an Neuro monitoring tech, do both EMG and NCS and bill/be paid for it?

do you need a medical license , so a PA or NP can do and bill for it?

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[avalon10]

Question for you all. I recognize that you Ll likely think this is a bad thing but my question isn’t about that but rather the legality of these situations?

Can a non physician bill for a needle EMG?
(I recognize that in many practices, the NCS are done by techs and the needle EMG by a physician and then the physician bills for both)

can some familiar with needle EMG like an Neuro monitoring tech, do both EMG and NCS and bill/be paid for it?

do you need a medical license , so a PA or NP can do and bill for it?

Physical therapist in my area does EMG/NCS, and patients tell me that he tells them that he has done "10,000" of them

 

[j4pac]

Physical therapist in my area does EMG/NCS, and patients tell me that he tells them that he has done "10,000" of them

Auditory recognition is just so important. It’s more important than visualizations of waveforms. If I saw an EMG read by a physician, but performed by someone else...it’s going into the trash where it belongs. Honestly, I’d trust a report by a PT that both perform and interpreted the findings of the EMG more than a physician just reading waveforms on a printout. That shouldn’t be billable. Don’t get me wrong...a PT shouldn’t be doing EMGs...neither should primary care providers. They are technically challenging studies and require someone familiar with neurology.

 

[Iamnew2]

Question for you all. I recognize that you Ll likely think this is a bad thing but my question isn’t about that but rather the legality of these situations?

Can a non physician bill for a needle EMG?
(I recognize that in many practices, the NCS are done by techs and the needle EMG by a physician and then the physician bills for both)

can some familiar with needle EMG like an Neuro monitoring tech, do both EMG and NCS and bill/be paid for it?

do you need a medical license , so a PA or NP can do and bill for it?

Can't bill for that. Also you are in serious crap if you misread the EMG portion surgery is done and something goes wrong.

 

[nvrsumr]

Chiros do EMGs in CO. Some are employed by neurosurgeons. As an aside I am not going to keep my ABEM certification. It doesnt matter one bit.

 

[Iamnew2]

Chiros do EMGs in CO. Some are employed ny neurosurgeons. As an aside I am not going to keep my ABEM certification. It doesnt matter one bit.

How is the EMG exam for board certification? It doesn't seem to be worth an ounce of energy but was just curious how challenging it is.

 

[nvrsumr]

I took it 10 years ago so not certain how it is now but was harder than PMR boards

 

[runfastnow]

Had a few attendings (both roughly 5 years into practice) in residency that sat for EMG boards. The studying they did made them much better/efficient at EMG, but board certification didn't change much for referrals, payments, etc.

They both commented that it was a very difficult test and much harder than PM&R boards, but even if they didn't pass the studying involved made them much better neuromuscular physicians for whatever that is worth to you.

 

[DMBandFan86]

As a counter argument, I saw plenty of PM&R docs doing bad EMGs in my training. Especially at the VA. One provider would only do NCS for a radiculopathy referral and then on another not do NCS because the patient had diabetes. I also saw plenty of people get surgery that didn’t help based on poor EMGs done by physicians .

Personally, that’s why I don’t do EMGs. I believe you really need to be a far level above what you get in general residency training to do it well. I just didn’t find it worthwhile to persue.

I haven’t seen an EMG done by a non physician but I’m sure they are out there. Interestingly though I have not heard about NP creap in the EMG world

 

[Iamnew2]

As a counter argument, I saw plenty of PM&R docs doing bad EMGs in my training. Especially at the VA. One provider would only do NCS for a radiculopathy referral and then on another not do NCS because the patient had diabetes. I also saw plenty of people get surgery that didn’t help based on poor EMGs done by physicians .

Personally, that’s why I don’t do EMGs. I believe you really need to be a far level above what you get in general residency training to do it well. I just didn’t find it worthwhile to persue.

I haven’t seen an EMG done by a non physician but I’m sure they are out there. Interestingly though I have not heard about NP creap in the EMG world

I don't do EMGs either. I don't find them personally useful and there are so many variations and issues and potential mishaps that I find them unhelpful.

 

[crunchymedicine]

Question for you all. I recognize that you Ll likely think this is a bad thing but my question isn’t about that but rather the legality of these situations?

Can a non physician bill for a needle EMG?
(I recognize that in many practices, the NCS are done by techs and the needle EMG by a physician and then the physician bills for both)

can some familiar with needle EMG like an Neuro monitoring tech, do both EMG and NCS and bill/be paid for it?

do you need a medical license , so a PA or NP can do and bill for it?

Saw a report by a PT that did NCS/EMG. Is it legal? The report had a PT society credential for electrodiagnostics after their name.
Would you accept the report or request repeat by physician?

 

[Iamnew2]

Saw a report by a PT that did NCS/EMG. Is it legal? The report had a PT society credential for electrodiagnostics after their name.
Would you accept the report or request repeat by physician?

If a surgeon accepts one of these reports by a non-physician they deserve to b sued for a bad outcome.

 

[xenotype]

If a surgeon accepts one of these reports by a non-physician they deserve to b sued for a bad outcome.

Jumping over from the neurology forum since I saw the thread title. This is the real key- anyone acting on an EMG from a non-PMR or neurologist is a fool interested more in their own $ than the patient's welfare. We have a huge, complicated thread on EMG fraud from a neurologist doing them who is probably horribly incompetent. An EMG from a PT is a joke that no one should take seriously- they aren't formally licensed to diagnose anything let alone find the subtle LEMS or ALS hiding in a routine study ordered by a surgeon who knows nothing about neuromuscular disease. Also- I really think anyone doing EMG should get the initial ABEM board at least to prove you sort of know what you are doing. Renewing it- material doesn't really change much but EMG is very hard to master and ABEM is at least a reasonable minimum bar.

Interestingly though I have not heard about NP creap in the EMG world

They took all the money out of EMGs years ago so you won't really see this, for this exact reason. Now the people who are good at EMGs have no incentive to do them, so patients just get screwed with incompetence or a months long waiting list. To those saying EMG isn't that useful- you can't really diagnose many myopathies or early MND without it, but an incompetent EMG will miss these anyways or overcall when they aren't there and a well done EMG should provide a lot of prognostic information for many problems that can be useful to surgeons. Doesn't replace a careful exam/history, but certainly can expand it.

 

[j4pac]

Jumping over from the neurology forum since I saw the thread title. This is the real key- anyone acting on an EMG from a non-PMR or neurologist is a fool interested more in their own $ than the patient's welfare. We have a huge, complicated thread on EMG fraud from a neurologist doing them who is probably horribly incompetent. An EMG from a PT is a joke that no one should take seriously- they aren't formally licensed to diagnose anything let alone find the subtle LEMS or ALS hiding in a routine study ordered by a surgeon who knows nothing about neuromuscular disease. Also- I really think anyone doing EMG should get the initial ABEM board at least to prove you sort of know what you are doing. Renewing it- material doesn't really change much but EMG is very hard to master and ABEM is at least a reasonable minimum bar.


They took all the money out of EMGs years ago so you won't really see this, for this exact reason. Now the people who are good at EMGs have no incentive to do them, so patients just get screwed with incompetence or a months long waiting list. To those saying EMG isn't that useful- you can't really diagnose many myopathies or early MND without it, but an incompetent EMG will miss these anyways or overcall when they aren't there and a well done EMG should provide a lot of prognostic information for many problems that can be useful to surgeons. Doesn't replace a careful exam/history, but certainly can expand it.

EMGs aren’t useful…when you have incompetent people performing them. I kid you not…I saw a neurologist needle 50 muscles on a NORMAL exam. I counted them…not exaggerating. Because you know…that 50th muscle is high yield for pathology when the first 49 are stone cold normal. Very rarely does he test below 25 muscles on a normal study. I’ve intentionally been referring elsewhere, but somehow they still get funneled to him. At this point I’m willing to give random joe-shmoe PT without any training a shot…because I have zero confidence that the neurologist knows what he’s doing (exaggerating, but just slightly).

But yeah…if you are basing tough clinical decisions on the opinion of an incompetent physician or professionals horribly undertrained in EMGs…then you deserve to be sued. But that’s not enough…the “credentialing board” should be sued. Their money grabbiness is what allows this to happen. They need to be shut down for the sake of patient safety.

 

[Iamnew2]

Jumping over from the neurology forum since I saw the thread title. This is the real key- anyone acting on an EMG from a non-PMR or neurologist is a fool interested more in their own $ than the patient's welfare. We have a huge, complicated thread on EMG fraud from a neurologist doing them who is probably horribly incompetent. An EMG from a PT is a joke that no one should take seriously- they aren't formally licensed to diagnose anything let alone find the subtle LEMS or ALS hiding in a routine study ordered by a surgeon who knows nothing about neuromuscular disease. Also- I really think anyone doing EMG should get the initial ABEM board at least to prove you sort of know what you are doing. Renewing it- material doesn't really change much but EMG is very hard to master and ABEM is at least a reasonable minimum bar.


They took all the money out of EMGs years ago so you won't really see this, for this exact reason. Now the people who are good at EMGs have no incentive to do them, so patients just get screwed with incompetence or a months long waiting list. To those saying EMG isn't that useful- you can't really diagnose many myopathies or early MND without it, but an incompetent EMG will miss these anyways or overcall when they aren't there and a well done EMG should provide a lot of prognostic information for many problems that can be useful to surgeons. Doesn't replace a careful exam/history, but certainly can expand it.

In my opinion very few people are truly good at EMGs. Good EMG'ers take time, and given the little money and significant time consumption of EMGs, it's not worth it for many doctors. I remember when I did pain fellowship the surgeon who was there tell me he was going to "train me" to do EMGs. I almost laughed. When I had done hundreds of EMGs with the world's best EMG'er. I was thinking nope, not what I am going to be doing on a fellowship. If you want an EMG'er, go hire one.

 

[sloh]

Do you guys feel patients would benefit most from getting EMG's done at academic centers? I've been out practicing for 2 years now and the EMG's I've seen performed by physicians in non-academic centers have been quite horrendous.

 

[Iamnew2]

Do you guys feel patients would benefit most from getting EMG's done at academic centers? I've been out practicing for 2 years now and the EMG's I've seen performed by physicians in non-academic centers have been quite horrendous.

I would agree. Academic centers probably would be best. there are such few EMGs - at least where I've practiced - that are done that most docs, both PM&R and Neuro do that it's hard for most private practice docs to truly be good at them. Obviously academics do this day in and day out and teach residents so they are most up to date with this. There just isn't the reimbursement to draw too many people to do them these days outside of academia.

 

[Taus]

Do you guys feel patients would benefit most from getting EMG's done at academic centers? I've been out practicing for 2 years now and the EMG's I've seen performed by physicians in non-academic centers have been quite horrendous.

If concerned about neuromuscular disease, ie myopathy, neuromuscular junction, motor neuron and the like… then yes. Otherwise for routine peripheral nerve entrapments such as carpal tunnel, ulnar at elbow, radic, traumatic peripheral nerve injury etc…. Then no.

 

[xenotype]

If concerned about neuromuscular disease, ie myopathy, neuromuscular junction, motor neuron and the like… then yes. Otherwise for routine peripheral nerve entrapments such as carpal tunnel, ulnar at elbow, radic, traumatic peripheral nerve injury etc…. Then no.

I agree. Quick CTS/ulnar/radic screens are the most straightforward part of EMG and the hardest to screw up, and also the most needed study by absolute numbers in the community- but I think a couple hundred studies in training are needed even to get to being able to do these competently. Academic centers are best for complex brachial plexopathy/MND/CIDP/MG etc. With that said, where I trained the NM department just loses money on clinical work because the complexity/time required for the cases. The straightforward stuff with a tech pays way better, and that is a huge problem for patient access. It's a 6-8 month+ wait at most academic centers to be seen for possible ALS...imagine if that was your parent waiting for a wheelchair, G tube placement, meds/botox etc. Some of the cases are very sad with how long people have waited, and in many cases having no idea what is wrong.

 

[xenotype]

EMGs aren’t useful…when you have incompetent people performing them. I kid you not…I saw a neurologist needle 50 muscles on a NORMAL exam. I counted them…not exaggerating. Because you know…that 50th muscle is high yield for pathology when the first 49 are stone cold normal. Very rarely does he test below 25 muscles on a normal study. I’ve intentionally been referring elsewhere, but somehow they still get funneled to him. At this point I’m willing to give random joe-shmoe PT without any training a shot…because I have zero confidence that the neurologist knows what he’s doing (exaggerating, but just slightly).

But yeah…if you are basing tough clinical decisions on the opinion of an incompetent physician or professionals horribly undertrained in EMGs…then you deserve to be sued. But that’s not enough…the “credentialing board” should be sued. Their money grabbiness is what allows this to happen. They need to be shut down for the sake of patient safety.

That's obscene. Even a 3 limb high complexity ALS study (let's say with a neuropathy or cervical injury clouding diagnosis) including tongue and thoracic paraspinals would be no more than 20 muscles at the most and that is a top level study. Still don't think that justifies PTs doing them. As you guys are probably aware there is no EMG numbers required in neuro residency as opposed to PMR, so any neurologist without CNP or NM fellowship probably doesn't know what they are doing unless they went to one of the small handful of neuro programs that has substantial dedicated EMG time without competition from fellows (then you have to worry about their EEG competence for those programs if no fellowship...)

 

[runfastnow]

Agree with above - I do sports med, interventional spine, and EMG in private practice setting. I do 5-6 EMG per week during clinic hours mainly for peripheral nerve entrapment and radic screens. I just do not have the time to do a 60 minute (much less multiple hour) EMG/NCS for ALS, NM disease, etc. like we would do in residency in EMG clinic (of course you sometimes will get someone that needs three limbs to confirm a peripheral neuropathy or a puzzling case that takes longer than you want). Beyond the time limitations I am not set up to properly care for these type patients so doing the study and assuming care would be inappropriate IMO unless I know this patient has literally no where else to go or needs EMG to even be seen by a neurologist or academic center.

I have maybe 3-4 of these type cases per year that come through that end up outside of the typical CTS or radic screen that I do for the practice. If it is obvious ALS or neuromuscular disease or something I suspect as "weird" on exam/history I let the patient know my limitations and even if I do the EMG and suspect ALS (or some other similar thing) I write it as such in my report and refer to academic neurology (no good academic PM&R near me) for more formal work up and/or confirmatory EMG.

I don't know if what I do is "correct" but it is the best I can offer patients that come to me.

 

[Axonotomesis911]

The Doctor of Physical therapy who I know in my area is board certified and residency trained in electrophysiology his reports are better than 90% of the neurologist and PMR docs I have seen. I believe he did 500 studies in his residency. He has picked up on ALS/NMJ and GBS. His reports are clear and very thorough which include physical exam. Some of the neuros reports in my area are not worth their weight in salt IT IS laughable and sad!!! I was against sending to a DPT at first but after seeing his reports and speaking to this guy he has is well trained. DPTs who ARE board certified in electrophysiology are allowed to furnish needle EMG without provision. Its easy to Sh**t on a profession that you dont know/understand, I made the same mistake.

 

[timisdaman]

The Doctor of Physical therapy who I know in my area is board certified and residency trained in electrophysiology his reports are better than 90% of the neurologist and PMR docs I have seen. I believe he did 500 studies in his residency. He has picked up on ALS/NMJ and GBS. His reports are clear and very thorough which include physical exam. Some of the neuros reports in my area are not worth their weight in salt IT IS laughable and sad!!! I was against sending to a DPT at first but after seeing his reports and speaking to this guy he has is well trained. DPTs who ARE board certified in electrophysiology are allowed to furnish needle EMG without provision. Its easy to Sh**t on a profession that you dont know/understand, I made the same mistake.

Interesting perspective! Which board certified the DPT, though?

 

[j4pac]

Says the physical therapist. Literally nothing of what you just said sounds like how a physician would relay such information. Literally your first sentence alone shows your true colors: “Doctor”, “board certified”, “residency trained.” Gtfo with that bull****. Your “doctoral” degree is a joke, one step above the nps joke of a degree— maybe even parallel. Finally, you didn’t do a residency ya quack.

Lol that escalated quickly. I don’t think that it is surprising that @Axonotomesis911 is a new member who’s only messages are in this thread and as an OP asking how much per day he/she should be making being contracted by an Ortho group to do EMGs.

 

[Sheldon]

Says the physical therapist. Literally nothing of what you just said sounds like how a physician would relay such information. Literally your first sentence alone shows your true colors: “Doctor”, “board certified”, “residency trained.” Gtfo with that bull****. Your “doctoral” degree is a joke, one step above the nps joke of a degree— maybe even parallel. Finally, you didn’t do a residency ya quack.

Maybe the new member is a PT, maybe not. However, FYI and a bit of perspective - the entry-level degree to PT is a doctorate of physical therapy (and has been for quite some time); it's typically a 3 year post-graduate degree and having gone through one, I will say it is not a joke.

Additionally, there are residencies in physical therapy (orthopaedics, neurologic, pediatric, sports, geriatric, electrophysiology, women's health, etc). I also completed one - an 18 month orthopaedic PHYSICAL THERAPY residency. Part of that was spending clinic hours doing exams with physicians, observing surgeries, 20 hours with a radiologist, and a lot of didactic course work. Once you complete a residency, you are eligible to sit for the orthopaedic certified specialist board examination, and if you pass, can use the "OCS" credential, a PHYSICAL THERAPY board certification. Approximately 300-400 PTs a year enter into a residency and there are approximately 10,000 PT graduates a year.

Lastly, there are also fellowships in physical therapy, the most prominent being fellowships in orthopaedic manual/manipulative physical therapy. Residencies and fellowships in physical therapy go through accreditation through our governing professional bodies.

I personally have all the above and an academic doctorate...but hey, you're a "physician." I also do not refer to myself as a "doctor" nor do I ask anyone to do so.

So SmokinJay6, you're wrong. Maybe do a bit of research before posting a reply after one too many bourbons. Glad you're not one of the physicians I learned from.

 

[j4pac]

Maybe the new member is a PT, maybe not. However, FYI and a bit of perspective - the entry-level degree to PT is a doctorate of physical therapy (and has been for quite some time); it's typically a 3 year post-graduate degree and having gone through one, I will say it is not a joke.

Additionally, there are residencies in physical therapy (orthopaedics, neurologic, pediatric, sports, geriatric, electrophysiology, women's health, etc). I also completed one - an 18 month orthopaedic PHYSICAL THERAPY residency. Part of that was spending clinic hours doing exams with physicians, observing surgeries, 20 hours with a radiologist, and a lot of didactic course work. Once you complete a residency, you are eligible to sit for the orthopaedic certified specialist board examination, and if you pass, can use the "OCS" credential, a PHYSICAL THERAPY board certification. Approximately 300-400 PTs a year enter into a residency and there are approximately 10,000 PT graduates a year.

Lastly, there are also fellowships in physical therapy, the most prominent being fellowships in orthopaedic manual/manipulative physical therapy. Residencies and fellowships in physical therapy go through accreditation through our governing professional bodies.

I personally have all the above and an academic doctorate...but hey, you're a "physician." I also do not refer to myself as a "doctor" nor do I ask anyone to do so.

So SmokinJay6, you're wrong. Maybe do a bit of research before posting a reply after one too many bourbons. Glad you're not one of the physicians I learned from.

Very few on this forum don’t value PTs substantially. PTs can be very good clinicians. But none of the fellowships you mentioned were EMG.

 

[Sheldon]

Very few on this forum don’t value PTs substantially. PTs can be very good clinicians. But none of the fellowships you mentioned were EMG.

Correct - there IS an electrophysiology residency accredited by ABPTFRE, but no electrophysiology f'ship for PTs.

 

[Axonotomesis911]

Says the physical therapist. Literally nothing of what you just said sounds like how a physician would relay such information. Literally your first sentence alone shows your true colors: “Doctor”, “board certified”, “residency trained.” Gtfo with that bull****. Your “doctoral” degree is a joke, one step above the nps joke of a degree— maybe even parallel. Finally, you didn’t do a residency ya quack.

Lol smokin joe needs to lay off the pipe!! and drop the inferiority complex, hilarious.

Yes I am DPT turned PMR as you can see from my dogmatic approach above. But I digress and return back to the intention of the original post.

I will NOT send patients to anyone who performs dreadful EMGs. I have neuros in my area calling sensor/motor DSPs when motor amplitudes/velocities are normal with no radic screen? Focal mononeuropathies out the ass with garbage reference norms and no physical symptoms. If physicians could read EMGs they would be appalled at the BS out there. I do about 4-5 EMGs a week in my practice but they eat my time/money.

 

[avalon10]

I’m glad I’m not the only one out there who thinks that the majority of EMGs are useless.

But physical therapists talking about their training in their “residency” and “fellowship” is laughable.

Leave practicing medicine up to the doctors.

 

[Sheldon]

I’m glad I’m not the only one out there who thinks that the majority of EMGs are useless.

But physical therapists talking about their training in their “residency” and “fellowship” is laughable.

Leave practicing medicine up to the doctors.

Get over yourself and off your high horse "doctor." Physical therapists practice physical therapy, not medicine.

 

[avalon10]

Get over yourself and off your high horse "doctor." Physical therapists practice physical therapy, not medicine.

It's hilarious that a "doctor" of physical therapy would put my Doctor title in quotes. I am an MD.
Physical therapists went from having associate degrees to bachelor degrees to masters, to now "doctorates." You are only a "doctor" because the powers that be realized that they could profit more by charging YOU more in tuition by keeping you in school longer to get your "doctorate."
You are doing the same job that people with associates and bachelor degrees used to do.
Your job is to teach people home exercise programs.
My horse is higher than yours for a reason.

 

[j4pac]

 

[wendalltwolf]

Does a typical 30 minute CTS/radic study still pay enough with typical insurance mixes, or do 3 follow ups during that same time yield more for reimbursement?

 

[runfastnow]

You may come out ahead with three follow ups if they are all 99214s, but if one (or certainly 2+) are 99213 or 99212 then probably not. It all depends on your collections and payor mix.

We average around $330 per single limb EMG/NCS study (without any other office visit charge) compared to three 99214 visits would be about $390 with our average payor mix and charges.

 

[wendalltwolf]

You may come out ahead with three follow ups if they are all 99214s, but if one (or certainly 2+) are 99213 or 99212 then probably not. It all depends on your collections and payor mix.

We average around $330 per single limb EMG/NCS study (without any other office visit charge) compared to three 99214 visits would be about $390 with our average payor mix and charges.

It’s interesting, I know many who simply stopped doing EMG’s due to those cuts earlier this decade. Unless they have residents and do several rooms, but then I’m sure they get bad eval’s for lack of teaching. Plus these days it seems more patients seems to be wusses and those high BMI folks probably end up unrecordable on NCS, even with max stim and duration.