The AANEM's Recommended Policy for Electrodiagnostic Medicine articulates the organization's position.

If you have questions, please contact the policy department at policy@aanem.org or 507.288.0100.

The scope of practice for physical therapists is defined by state laws and the rules enacted by the Board of Physical Therapy in each individual state. However, in many instances, no specific provisions exist on whether or not physical therapists can perform or interpret needle EMG, leaving the issue open for interpretation by the Board of Physical Therapy. In some states, conflicting opinions of the Board of Physical Therapy and the Board of Medicine may co-exist on the issue of needle EMG. Since each board is autonomous in regulating its respective profession and cannot impose its rules or opinions on other health professions (for example, the Board of Medicine is unable to define scope of practice for physical therapists), such conflicting opinions would be considered equally valid, unless it could be demonstrated that one of them violates state laws.

It is the AANEM’s position that physical therapists are not qualified to perform or interpret EMG. You can refer to the AANEM’s Who is Qualified to Practice Electrodiagnostic Medicine Policy for more information. This position is supported by the research of Dr. Timothy R. Dillingham, Chair of the Department of Physical Medicine and Rehabilitation at the University of Pennsylvania, School of Medicine. Dr. Dillingham’s research examined private payer claims data from 6381 electrodiagnostic encounters for persons with diabetes. Polyneuropathy diagnosis rates were highest for electrodiagnostic physicians—over 12%—compared to 2.1% by physical therapists.  A later Dillingham study analyzing Medicare claims also demonstrated a significant difference between electrodiagnostic physicians and non-physician providers (including chiropractors, podiatrists, physical therapists, occupational therapists, nurse practitioners and physician assistants); the specialist physicians  were  26% more likely to diagnose polyneuropathy than non-physicians. Significant disparities in recognizing a particular condition may suggest “that quality of electrodiagnostic care may be deficient when it is provided by those without requisite training and specialized knowledge.”

A review of several physical therapy training programs found little evidence that needle EMG is a part of the standard curriculum for physical therapists. There is, however, a program at the Rocky Mountain University that is providing a Doctor of Science (DSc) in clinical electrophysiology. The American Board of Physical Therapy Specialties (ABPTS) has developed an examination for select physical therapists that perform electrophysiology studies. The ABPTS requires that the applicant self-reports evidence of 2000 hours of direct patient care, 500 of which must have occurred in the previous 3 years. Not all of those hours must be dedicated exclusively to electrodiagnostic testing. However, the applicant is required to submit evidence of 500 complete electroneuromyography examinations during those 2000 hours.

Medicare provides coverage for EMGs performed by physical therapists if the physical therapist has completed certification in clinical electrophysiology through the ABPTS. Additionally, Medicare allows certified clinical electrophysiology physical therapists to personally supervise other physical therapists’ performance of EMG. The analysis of Medicare claims demonstrates a steady increase in a number of needle EMG claims filed by physical therapists in recent years. The AANEM maintains scope of practice information on each state and all AANEM members are encouraged to contact the organization with questions about the status of physical therapists in their state. AANEM members are also asked to submit examples of poor quality studies (in a manner that is compliant with HIPAA and any other regulations protecting patient’s privacy) for use in future advocacy efforts regarding this issue.

While Medicare is a federal insurance program, local contractors administer the program in each jurisdiction. Jurisdictions are comprised of several states in a region. The local contractors in each jurisdiction are called Medicare Administrative Contractors (MACs), which were previously referred to as Local Carriers. Coverage decisions are made both by Medicare for national coverage issues and by MACs for local coverage decisions. MACs are required to follow national coverage decisions in adjudication of claims. An example of a national coverage decision is the policy that states physical therapists certified in clinical electrophysiology by the American Board of Physical Therapy Specialists will be paid by Medicare for performing and interpreting EMGs unless prohibited by state law. The MACs cannot make a policy that contradicts this policy. Local Coverage Determinations (LCDs) vary in each jurisdiction. An example is the electrodiagnostic LCD for Florida developed by First Coast Service Options. This LCD includes several elements that the AANEM believes support the performance of quality electrodiagnostic medicine studies. The LCD notes that both EMG and nerve conduction study are required for some diagnoses. The LCD states that consistent, excessive claims will be reviewed.

Finally, the LCD highlights that services provide by neurologists and physiatrists are covered; all others must demonstrate competency through training in an applicable residency or fellowship or very extensive CME. This LCD is only applicable to the state within First Coast’s jurisdiction, which includes Florida, Puerto Rico and U.S. Virgin Islands. Sometimes MACs have similar LCD language, but often they are different. You can find the MAC that covers your jurisdiction and each MAC’s coverage decisions at aanem.org.

The Medicare SGR (sustainable growth rate) is a method currently used by Centers for Medicare & Medicaid Services (CMS) to control spending by Medicare on physician services. The SGR is based on the following factors: 1) the estimated change in fees for physicians’ services, 2) the estimated change in beneficiaries enrolled in Medicare’s fee-for-service program, 3) the estimated growth in real gross domestic product (GDP) per capita, and 4) the estimated change in expenditures due to law and regulation. Generally, SGR is a method to ensure that the yearly increase in the expense per Medicare beneficiary does not exceed the growth in the GDP. Via the GDP, the SGR formula is linked to the performance of the overall economy, which is a major flaw in the formula because the metric conflicts with the medical needs of patients which don’t fluctuate with the economy. The SGR effectively caps total Medicare expenditures on physician services. If utilization of physician services increased above this arbitrary target growth rate, the reimbursement per service performed actually drops.

Every year since 2001, the threat of severe physician payment cuts, imposed by Medicare’s  SGR formula, have jeopardized the stability of the Medicare system and compromised access to care for patients. And every year – sometimes several times a year – Congress has put in place short-term fixes to stall the cuts.  Congress’ interventions without any reforms to the formula have only exacerbated the problem. Cuts for physician reimbursement are now expected to be approximately 20%, with expected cuts of almost 40% by 2016 if a fix is not approved.
 

The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional advisory board that historically has given Congress recommendations as to needed SGR adjustments. The Commission reviews the previous year’s total expenditures, the target expenditures, and the conversion factor that will change the Medicare payments for physician services for the next year to match the target SGR. If the expenditures for the previous year exceeded the target expenditures, the conversion factor will decrease payments for the next year. The reverse would be true if the expenditures declined.
 

In the fall of 2011, MedPAC recommended repealing the SGR formula and imposing a 10-year freeze of payments to Medicare primary care physicians.  Included in their recommendations were plans to replace SGR with a 10-year alternative funded in part through Medicare cuts of a 5.9% to specialty providers for 3 straight years, followed by a 7-year payment freeze.
 

However, MedPAC’s recommendations are non-binding and require congressional action to be implemented. Congress can react to MedPAC recommendations in sharply different and unpredictable ways — and it often chooses to ignore them altogether.
 

In 2010, in response to the nation’s fiscal challenges, President Obama created the bipartisan National Commission on Fiscal Responsibility and Reform. The Commission is charged, in part, with identifying policies to improve the healthcare fiscal situation in the medium term (years 2015 to 2020) and to achieve fiscal sustainability over the long run.   This group has been the target of extensive lobbying from the healthcare industry to replace the cuts required by SGR with modest reductions while directing CMS to establish a new payment system, beginning in 2015, to reduce costs and improve quality. In its report, issued in December of 2010, the Commission recommended a freeze of payments in 2013, followed by a 1% cut in 2014 and reintroduction of the SGR formula in 2015 as a temporary measure until a new payment system is developed. The report did not receive sufficient support from the members of the Commission and as a result the Congress was not required to vote on it.

Congress also created the Independent Payment Advisory Board (IPAB), to control the growth of Medicare spending. Its goal is to reduce the rate of growth in Medicare without affecting coverage or quality.  Unlike the MedPac, recommendations from the IPAB will become law unless the House and the Senate each adopt, by a three-fifths majority, a resolution to block them. If the President vetoes the resolution, two-thirds of each chamber will have to vote to override the veto in order to block the recommendations.

To preserve access to health care, the AANEM urges its members to contact their U.S. senators and representatives and let them know that now is the time to repeal the Medicare physician-payment formula to protect everyone’s access to health care.