Group 1 Paragraph: N/A
Group 1 Codes:
95921 Autonomic nrv parasym inervj
95922 Autonomic nrv adrenrg inervj
95923 Autonomic nrv syst funj test
95924 Ans parasymp & symp w/tilt
95943 Parasymp&symp hrt rate test
Coverage Indications, Limitations, and/or Medical Necessity
The aim of Autonomic Nervous System (ANS) testing is to correlate signs and symptoms of possible autonomic dysfunction with objective measurement in a fashion that is clinically useful.
ANS testing can be grouped into three general categories:
Cardiovagal innervation (CPT code 95921) - A test that provides a standardized quantitative evaluation of vagal innervation to parasympathetic function of the heart. Responses are based on the interpretation of changes in continuous heart recordings in response to standardized maneuvers and include heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio heart rate responses to standing.
Vasomotor adrenergic innervation (CPT code 95922) - Evaluates adrenergic innervation of the circulation and of the heart in autonomic failure. The following tests are included: beat-to-beat blood pressure and R-R interval response to Valsalva maneuver, sustained hand grip, and blood pressure and heart rate responses to tilt-up or active standing.
(Do not report 95922 in conjunction with 95921)
Sudomotor function testing (CPT code 95923) - Used to evaluate and document neuropathic disturbances that may be associated with pain. The quantitative sudomotor axon reflex test (QSART), thermoregulatory sweat test (TST), sympathetic skin responses, and silastic sweat imprints are tests of sympathetic cholinergic sudomotor function.
The QSART measures axon reflex-mediated sudomotor responses quantitatively and evaluates post-ganglionic sudomotor function. Recording is usually carried out from the forearm and three lower extremity skin sites to assess the distribution of post-ganglionic deficits.
The TST evaluates the distribution of sweating by a change in color of an indicator powder. This test has a high sensitivity, and its specificity for delineating the site of lesion is greatly enhanced when used in conjunction with QSART.
Sweat imprints are formed by the secretion of active sweat glands into a plastic (silastic) imprint. The test can determine sweat gland density, a histogram of sweat droplet size and sweat volume per area.
Combined parasympathetic and sympathetic testing with and without the use of a tilt table are coded as follows:
Combined parasympathetic and sympathetic adrenergic functions with at least 5 minutes of passive tilt (CPT code 95924) – This should be reported only when both the parasympathetic and the adrenergic functions are tested together with the use of a tilt table.
(Do not report 95924 in conjunction with 95921 or 95922.)
Simultaneous, independent, quantitative measures of both parasympathetic function and sympathetic functions based on time-frequency analysis of continuous respiratory activity, with mean heart rate and blood pressure measures, during rest, paced (deep) breathing, Valsalva maneuvers, and head-up postural change (CPT code 95943) - This is autonomic function testing that does not include beat-to-beat recording or testing without the use of a tilt table.
(Do not report 95943 in conjunction with 93040, 95921, 95922, 95924.)
Appropriate application and interpretation of ANS testing requires a detailed knowledge of the testing criterion and a match between the tests of suspected clinical/functional impairment with the autonomic activity being tested. Most autonomic disorders are diagnosed clinically, with laboratory and formal diagnostic testing playing an adjunctive or confirmatory role. Testing may also be appropriate to monitor disease progression when there is a change in clinical status, or to evaluate a patient’s response to specific treatment for an autonomic disorder.
Autonomic function testing is covered as reasonable and necessary when used as a diagnostic tool to evaluate symptoms indicative of vasomotor instability, such as hypotension, orthostatic tachycardia, and hyperhidrosis after more common causes have been excluded by other testing, and the ANS testing is directed at establishing a more accurate or definitive diagnosis or contributing to clinically useful and relevant medical decision making for one of the following indications:
To diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a progressive autonomic neuropathy.
To evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy.
To differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of consciousness.
To evaluate inadequate response to beta blockade in vasodepressor syncope.
To evaluate distressing symptoms in a patient with a clinical picture suspicious for distal small fiber neuropathy in order to diagnose the condition.
To differentiate the cause of postural tachycardia syndrome.
To evaluate change in type, distribution or severity of autonomic deficits in patients with autonomic failure.
To evaluate the response to treatment in patients with autonomic failure who demonstrate a change in clinical exam.
To diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient.
To evaluate and treat patients with recurrent unexplained syncope to demonstrate autonomic failure, after more common causes have been excluded by other standard testing.
Syndromes of autonomic dysfunction for which ANS might add valuable clinical information are relatively rare. Generally, only after excluding more common causes of autonomic signs or symptoms (e.g., hypotension, hyperhidrosis, and orthostatic tachycardia) may formal autonomic testing be indicated to exclude or confirm rarer autonomic disorders. The following indications are not considered medically reasonable and necessary and will not be covered:
To screen patients without signs or symptoms of autonomic dysfunction, including patients with diabetes, hepatic or renal disease.
To test for the sole purpose of monitoring disease intensity or treatment efficacy in diabetes, hepatic or renal disease.
To test where the results are not used in clinical decision-making and patient management.
Testing performed by physicians who do not have evidence of training, and expertise to perform and interpret these tests. (Physicians must have knowledge, training, and expertise to perform and interpret these tests, and to assess and train personnel working with them.)
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
99999 Not Applicable
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
E10.40 - E10.49 - Opens in a new window Type 1 diabetes mellitus with diabetic neuropathy, unspecified - Type 1 diabetes mellitus with other diabetic neurological complication
E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E11.40 - E11.49 - Opens in a new window Type 2 diabetes mellitus with diabetic neuropathy, unspecified - Type 2 diabetes mellitus with other diabetic neurological complication
E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E13.40 - E13.49 - Opens in a new window Other specified diabetes mellitus with diabetic neuropathy, unspecified - Other specified diabetes mellitus with other diabetic neurological complication
E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy
E85.0 - E85.9 - Opens in a new window Non-neuropathic heredofamilial amyloidosis - Amyloidosis, unspecified
G23.0 - G23.9 - Opens in a new window Hallervorden-Spatz disease - Degenerative disease of basal ganglia, unspecified
G60.3 - G60.9 - Opens in a new window Idiopathic progressive neuropathy - Hereditary and idiopathic neuropathy, unspecified
G90.09 Other idiopathic peripheral autonomic neuropathy
G90.3 Multi-system degeneration of the autonomic nervous system
G90.50 - G90.59 - Opens in a new window Complex regional pain syndrome I, unspecified - Complex regional pain syndrome I of other specified site
I95.1 Orthostatic hypotension
R00.0 Tachycardia, unspecified
R55 Syncope and collapse
R61 Generalized hyperhidrosis