CAM 20103

Gait Analysis

Category:Other   Last Reviewed:December 2020
Department(s):Medical Affairs   Next Review:December 2999
Original Date:December 1995    

Description:
Gait analysis is the quantitative laboratory assessment of coordinated muscle function, typically requiring a dedicated facility and staff and analysis of a video-recorded observation of a patient walking. Gait analysis has been proposed as an aid in surgical planning, primarily for children with cerebral palsy. It is also a potential tool to help plan rehabilitative strategies for ambulatory problems related to cerebral palsy, aging, stroke, spinal cord injury and other conditions.

Background
Gait analysis is the quantitative assessment of coordinated muscle function; evaluation is conducted in a laboratory and typically involves a dedicated facility and staff. A visual assessment of walking is supplemented by video recording. Videos can be observed from several visual planes at slow speed, allowing detection of movements not observable at normal speed. Joint angles and various time-distance variables, including step length, stride length, cadence and cycle time, can be measured. Electromyography (EMG), assessed during walking, measures timing and intensity of muscle contractions. This calculation allows determination of whether a certain muscle’s activity is normal, out of phase, continuous or clonic.

Kinematics is the term used to describe movements of joints and limbs, such as angular displacement of joints and angular velocities and accelerations of limb segments. The central element of kinematic assessment is some type of marker system that is used to represent anatomic landmarks, which are then visualized and quantitatively assessed by videotaped observations or optoelectronic data. Movement data are compiled by computer from cameras oriented in several planes, and the movement data are processed so that the motion of joints and limbs can be assessed in 3 dimensions. The range and direction of motion of a particular joint can be isolated from all the other simultaneous motions that are occurring during walking. Graphic plots of individual joint and limb motion as a function of gait phase can be generated.

Inertial and magnetic measurement systems (IMMSs) are under investigation for the assessment of joints and limbs in 3-dimensions.(1,2) Rather than videotaped or optoelectronic calibration of markers placed on anatomic landmarks, IMMS systems involve sensor units that comprise miniaturized 3-dimensional accelerometers, gyroscopes and magnetometers that are attached to body segments. The 3-dimenstional orientation of each sensor is measured in relationship to an Earth-based coordinate system through the use of computerized algorithms. One protocol, the "Outwalk" protocol, has been developed to allow the use of an IMMS system for gait analysis.

Gait analysis has been proposed as an aid in surgical planning, primarily for cerebral palsy, but also for other conditions such as clubfoot. In addition, gait analysis is being investigated as a means to plan rehabilitative strategies (i.e., orthotic-prosthetic devices) for ambulatory problems related to cerebral palsy, aging, stroke, spinal cord injury, etc.

A nonprofit organization established in 1997, the Commission for Motion Laboratory Accreditation, evaluates and accredits motion laboratories within clinical facilities. A multidisciplinary team uses a set of criteria to evaluate laboratories in the areas of administration (e.g., staffing, policies, procedures), equipment (e.g., accuracy and precision) and data management and reporting (e.g., control and clinical data sets).

Regulatory Status
In May 2003, the Peak Motus Motion Measurement System (Peak Performance Technologies) was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. This system uses off-the-shelf video cameras and sensors and proprietary software to document human movement in 2- or 3-dimensional space. The FDA determined that this device was substantially equivalent to existing devices and is indicated for assessment and training of limb or body motion in gait analysis, pre- or postrehabilitation evaluation, physical therapy and similar applications.

In January 2004, the Coda cx1 Motion Analysis System (Charnwood Dynamics Ltd., Rothley, Leicestershire, U.K.), was cleared for marketing by FDA through the 510(k) process. The system uses infrared light sight sensors and software data analysis to measure the 3-dimensional movement of patients. FDA determined that the device was substantially equivalent to existing devices and is indicated for analysis of the 3-dimensional motion of the limbs and body of patients who have some impairment of movement functions due to a neurologic or orthopedic cause.

Related Policies
20102 Dynamic Posturography

Policy:  
Comprehensive gait analysis may be considered MEDICALLY NECESSARY as an aid in surgical planning in patients with gait disorders associated with cerebral palsy.

Comprehensive gait analysis is considered INVESTIGATIONAL for all other applications. including, but not limited to:

  • Surgical planning for conditions other than gait disorders associated with cerebral palsy.
  • Postoperative evaluation of surgical outcomes and rehabilitation planning and/or evaluations for all conditions.

Gait analysis that is not comprehensive is considered INVESTIGATIONAL.

Policy Guidelines
Comprehensive gait analysis includes a quantitative assessment of coordinated muscle function in a dedicated laboratory and uses the codes listed below:

96000: Comprehensive computer-based motion analysis by videotaping and 3-D kinematics

96001: Above with dynamic plantar pressure measurements during walking

96002: Dynamic surface electromyography, during walking or other functional activities, 1–12 muscles

96003: Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle

96004: Physician review and interpretation of comprehensive computer-based motion analysis, dynamic plantar pressure measurement, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report.

Benefit Application
BlueCard®/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all devices approved by FDA may not be considered investigational. Therefore, FDA-approved devices may only be assessed on the basis of their medical necessity.

Rationale:
This policy was developed in 1995 and modified based on a 2001 TEC Assessment on gait analysis in cerebral palsy.(3) At the time of the TEC assessment, there were no generally recognized standards of performance and interpretation of gait analysis and only limited reference standards to use for evaluating the accuracy of gait analysis. Gait analysis had been used extensively as an outcome tool in research on gait; however, there was only 1 small published case series addressing improved patient outcomes due to gait analysis in cerebral palsy. Gait analysis was considered investigational for all applications. Since the TEC assessment, the policy was updated regularly with a literature review using MEDLINE, most recently through Jan. 1, 2014. Following is a summary of key literature to date on gait analysis.

Accuracy/Reliability
A systematic review of 18 studies on gait classification systems was published in 2007.(4) The review included studies that involved classification of gait impairment based on kinematic, temporal-spatial kinetic or electromyographic (EMG) data. Fifteen studies used 3-dimensional gait analysis, 1 study used video observation analysis and 6 studies used EMG data. The authors assessed the overall methodologic quality of the studies as low. Many studies appeared to classify patients arbitrarily rather than use clear clinical decision-making principles. Only 2 studies evaluated the reliability of classification, and the methods for determining the validity of classification systems was found inadequate. In 2009, McGinley et al. published a systematic review of studies of intersession and interassessor reliability of 3-dimensional kinematic gait analysis that included 15 full manuscripts and 8 abstracts.(5) Similar to the Dobson systematic review, the authors noted variability in methodologic quality across the studies, but concluded that most studies demonstrated interassessor error of between 2 and 5 degrees of measurement, which the authors considered was "reasonable but may require consideration in data interpretation." Benedetti et al. conducted an analysis of between-site consistency in gait analysis measurements of 1 healthy subject at 7 different laboratories.(6) The authors concluded that there was generally high concordance of segment and joint kinematics, except in the knee and the hip.

In an earlier study funded by the United Cerebral Palsy Foundation, 4 different gait analysis centers gave different treatment recommendations after evaluating the same 11 patients.(7) Thus, there appears to be inconsistency in gait analysis recommendations between some centers.

Impact on Health Outcomes
The ideal study design to evaluate the utility of gait analysis for surgical planning or evaluation or rehabilitation planning would be a randomized controlled trial (RCT) and would compare health outcomes in patients managed with gait analysis to patients managed using another approach.

Pre- and/or Postsurgical Evaluation for Children with Cerebral Palsy
There is 1 RCT, published in 2012 by Wren et al., comparing postsurgery health outcomes in children with cerebral palsy who were managed with and without gait analysis.(8) This was a single-center, single-blind study. The trial included 186 ambulatory children with cerebral palsy who were candidates for lower-extremity surgery to improve their gait. All participants underwent gait analysis at a gait laboratory. Patients were randomized to a treatment group in which the surgeon received the gait analysis report or a control group in which the surgeon did not receive the report. The reports included a summary of test results and treatment recommendations from the gait laboratory physician. The same surgeons treated the intervention and control patients, i.e., they received gait reports for half of the patients. Patients were re-examined the day before surgery (i.e., following gait analysis) for preoperative treatment planning. Outcomes were assessed preoperatively and approximately 1 year postsurgery. There were 3 primary outcomes: pre- to postsurgical change between groups in the walking scale of the Gillete Functional Assessment Questionnaire, the Gait Deviation Index and the oxygen cost of walking, a measure of the energy expended while walking (oxygen, cost). A total of 156 of 186 (84%) participants returned for the follow-up examination; analysis was not intention to treat. There was not a statistically significant difference between groups in any of the 3 primary outcomes. For example, the proportion of patients improved according to the Functional Assessment Questionnaire was 31% in the intervention group and 25% in the control group (p=0.38). There were significant differences between groups at the p=0.05 level for 2 of 19 secondary outcome variables; p values were not adjusted for multiple comparisons. The authors noted that physicians followed only 42% of recommendations in the gait analysis report for patients in the treatment group, which may partially explain the lack of significant differences between groups in the primary outcomes and most of the secondary outcomes. They further noted that there was a positive relationship between gait outcomes and following gait analysis recommendations.

In 2013, Wren et al. published a secondary analysis of data from the RCT previously described to evaluate the impact of gait analysis on the correction of excessive internal hip rotation among ambulatory children with cerebral palsy.(9) In the secondary analysis, the authors included the subset of children for whom the gait laboratory recommended external femoral derotation osteotomy (FDRO) to correct excessive passive and active internal hip rotation and who had both pre- and postoperative data available. As in the primary study, the intervention was receipt of the gait analysis report by the treating orthopedic surgeon for participants in the intervention group; in this subset of patients, all patients had FDRO recommended by the gait analysis report, but the decision to actually perform surgery was up to the treating surgeon. Physical measurements for this subanalysis included femoral anteversion, maximum hip internal and external rotation range of motion and rotational alignment during gait. The primary outcome variables included femoral anteversion and mean hip rotation and foot progression in the stance phase of gait. Outcomes postsurgery and change in variables pre- to postsurgery were compared between intervention and control groups, with additional analyses based on whether patients in the gait report (intervention) group had had the gait report recommendations followed. This subanalysis included 44 children (65 limbs) for whom FDRO was recommended. FDRO was performed in 7/39 limbs in which it was recommended in the gait report (intervention group); it is not clear how many children in the control group for whom FDRO was recommended received surgery. There were no significant differences in outcomes between the gait report and control groups on intent-to-treat analysis. However, among children in the intervention group who had FDRO done (n=7 limbs), the limbs demonstrated greater improvements in femoral anteversion (-32.9° vs. -12.2°; p=0.01), dynamic hip rotation (-25.5° vs. -7.6°; p=0.001) and foot progression (-36.2° vs. -12.4°; p=0.02) than limbs in the control group. The discrepancy between the intent-to-treat and per-protocol results may be related to generally poor compliance with the gait report recommendations, as only 7 of 39 recommended FDROs were performed in the gait analysis group. Interpretation of this study’s significance is limited by its subgroup analysis design and the small number of patients who received gait analysis and FDRO.

Previously, in 2009, Wren et al. published a retrospective, nonrandomized study comparing outcomes in patients managed with and without gait analysis.(10) The analysis included 462 children with cerebral palsy who had undergone lower-extremity orthopedic surgery at a single hospital and had at least 6 months’ follow-up (n=313 had gait analysis before surgery and n=149 did not). Adjusting for baseline differences, the overall finding was that the number of procedures and costs did not differ significantly between groups. The group that received gait analysis had a mean of 2.6 procedures per person-year compared with 2.3 per person-year in the nongait analysis group. In subanalyses, patients in the gait analysis group had significantly more initial surgical procedures (5.8 vs. 4.2, p<0.01) than the group that did not have gait analysis. Conversely, patients in the group not managed with gait analysis had more subsequent procedures (32% vs. 11%, p<0.001 – all respectively). Study findings suggest that gait analysis does not significantly affect overall utilization and cost. This study, however, did not specifically evaluate health outcomes. Also, since the study was not randomized, there may have been uncontrolled baseline differences that affected the number of procedures received.

In addition, several uncontrolled studies have been published in which children underwent both pre- and postoperative gait analysis. For example, in a study by Lofterod et al., 60 children with cerebral palsy were referred for gait analysis after development of an initial surgical plan based on clinical observation. (11,12) The original surgical plans were found to have been modified in 70% of patients following multidisciplinary team gait analysis. In a follow-up report, patients were divided into 3 groups: group A: Agreement between clinical evaluation, gait analysis and subsequent surgery; group B: Procedures performed due to gait analysis recommendations that had not been part of the initial surgical plan; group C: Procedures that were part of the initial surgical plan were not performed because they were not recommended after gait analysis. Based on gait analysis interpretation, surgery was not recommended in 11 children. Fifty-five children, including 47 who received surgery, underwent follow-up gait analysis 1 to 2 years after the initial analysis. Overall, at follow-up, there was improvement in kinematic parameters for children in groups A and B. This suggests that the change in treatment planning associated with gait analysis may have been beneficial, or at least not harmful; we do not know what the outcome would have been if the original treatment plan had been followed. Group C had fewer surgical procedures or no surgery; among children in this group, there were no statistically significant changes in any kinematic parameters at the follow-up gait analysis. Of the 8 children in group C, 4 children had clinical deterioration during more than 2 years of follow-up and were recommended to have multilevel surgery; most of their kinematic parameters were in the normal range at the time of initial evaluation. Based on this case series of patients referred for gait analysis, the authors concluded that gait analysis was useful for surgical planning.

Another study reviewed outcomes in 45 children with cerebral palsy who underwent gait analysis before and approximately 1 year after surgery that included collection of 3-dimensional motion and force-plate data.(13) The study aimed to determine whether gait analysis had a positive impact on treatment plans and whether gait analysis could predict which children would benefit from surgery. Most children had approximately 1 year between examinations. Like the Lofterod et al. study, patients were retrospectively classified into 3 groups, each with 15 children. A key outcome measure was change in the Gillette Gait Index (GGI); the article states that a change of 10% in the index is clinically significant. Based on change in the GGI, among the 15 children for whom surgery was not recommended, 7 children improved, 4 were stable and 4 deteriorated. In the group that had surgery recommended but not performed (due to family preference or other factors), 6 of 15 children improved, 1 was stable and 8 deteriorated. In the group for whom surgery was recommended and performed, 12 children improved and 3 remained stable. A limitation of this study is that the authors did not prospectively collect data on how treatment plans changed after the gait analysis; instead, this was estimated by a multivariate analysis that found a significant association between the GGI and choice of treatment, which the authors believe suggests that gait data influenced the treatment decision.

Schwartz et al. published an evaluation of the role of a random forest algorithm (a statistical method used to predict an outcome for a particular observation based on a series of predictor values) that included gait analysis to predict outcomes after single-event, multilevel surgery for patients with ambulatory cerebral that either did or did not include psoas lengthening.(14) The study authors report that their random forest algorithm was able to generate criteria that are predictive of good outcomes for patients undergoing a single-event, multilevel orthopedic surgery. However, the study was based on a retrospective analysis of a motion analysis center database and is thus subject to bias. In addition, the complexity of the random forest decision algorithm makes it difficult to determine the degree to which gait analysis independently predicts outcomes.

In 2011, prior to the publication of the RCT just described,(8) Wren et al. published a systematic review of literature on the efficacy of gait analysis.(15) The authors identified 7 studies evaluating the effect of gait analysis on patients’ health outcomes; none were RCTs. The studies addressed a variety of clinical conditions, and the authors were not able to pool findings. The systematic review also identified studies evaluating other aspects of gait analysis, including technical accuracy, diagnostic accuracy and societal efficacy (i.e., impact on number and cost of procedures). The authors concluded that, although there is lower-level evidence (e.g., case series, case-control studies) supporting gait analysis, there is a lack of evidence from RCTs on the effect of gait analysis on health outcomes.

Section Summary
Primary results and 1 subgroup analysis from 1 RCT have been published comparing outcomes in patients with cerebral palsy managed with and without gait analysis. The study did not find better health outcomes in patients managed with gait analysis; however, surgeons followed only a minority of recommendations in the gait analysis reports, and this trial is not definitive in ruling out a beneficial impact. Overall, there is insufficient evidence from RCTs that gait analysis prior to surgery improves health outcomes in patients with cerebral palsy.

Pre- and/or Postsurgical Evaluation for Conditions Other than Cerebral Palsy
In a study by Suda et al., gait analysis recommendations in 60 patients with neurogenic intermittent claudication were evaluated and compared with 50 healthy controls.(16) The authors concluded that gait analysis provided useful quantitative and objective information to evaluate postsurgical treatment. However, the study does not address how the gait analysis influenced treatment decisions or affected health outcomes.

Sankar et al. received the records of 35 children (56 feet) who had recurrent deformity after treatment of idiopathic clubfoot.(17) Gait lab recommendations were compared with surgical plans prior to gait analysis and to actual surgery received. Thirty of 35 (86%) children underwent surgery. Gait analysis resulted in changed procedures in 19 of 30 (63%) patients. Gait analysis was found to influence clinical decisions, but, like the study by Suda et al., this study does not evaluate whether these changes resulted in improved health outcomes.

Gait analysis has been used in the assessment of multiple other conditions (e.g., knee pain in older patients with osteoarthritis,(18) gait after acute stroke(19) and of frailty in older patients(20)); however, the evidence linking the use of gait analysis to outcomes in these conditions is limited.

Section Summary
There is insufficient evidence that gait analysis as part of surgical planning improves health outcomes in patients with conditions other than cerebral palsy.

Rehabilitation Planning and/or Evaluation
No relevant clinical studies were identified.

Ongoing Clinical Trials
A search of online site ClinicalTrials.gov on Jan. 13, 2014, using "gait analysis" as a text phrase in the intervention field, returned a total of 17 actively recruiting trials. The following are trials that use gait analysis as an intervention:

  • Outcomes of orthopedic surgery using gait laboratory versus observational gait analysis in children with cerebral palsy (NCT00419432)(21): This is a double-blind RCT evaluating whether the addition of gait analysis to routine observation improves surgical outcomes in ambulatory children with cerebral palsy. Outcomes include measures of motor function and general functioning, e.g., in the home and at school. The investigators intend to enroll 50 children in the study, which is being conducted at sites in the United States and Canada. The estimated date of study completion is October 2014.

Clinical Input Received through Physician Specialty Societies and Academic Medical Centers
In response to requests, input was received from 3 specialty societies (7 reviewers) and 2 academic medical centers (4 reviewers) while this policy was under review in 2010. While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. The reviewers generally disagreed with the statement that gait analysis is investigational for all indications. There was agreement among the reviewers that comprehensive gait analysis (i.e., involving analysis of video recordings) may be medically necessary as an aid in surgical planning for children with gait disorders associated with cerebral palsy. Specifically, in children with cerebral palsy, reviewers consider comprehensive gait analysis to be important for planning prior to bony or muscle surgery in the lower extremities.

Summary
Gait analysis is the quantitative assessment of coordinated muscle function. For patients with cerebral palsy undergoing surgery for gait disorders, 1 randomized controlled trial (RCT) did not find improvement in health outcomes for patients who received gait analysis as part of surgical planning, and 1 non-RCT did not find improvement in utilization parameters. Several studies conducted among patients with cerebral palsy and other conditions suggest that gait analysis recommendations impact treatment decisions, but the impact of these decisions on health outcomes is as yet unknown. Based on input from clinical reviewers, gait analysis, when comprehensive, may be medically necessary for planning before surgery in children with gait disorders associated with cerebral palsy. Due to insufficient evidence, gait analysis is considered investigational for all other indications.

References 

  1. Cutti A, Ferrari A, Garofalo P et al. ‘Outwalk’: a protocol for clinical gait analysis based on inertial and magnetic sensors. Med Biol Eng Comput 2010; 48(1):17-25.
  2. van den Noort JC, Ferrari A, Cutti AG et al. Gait analysis in children with cerebral palsy via inertial and magnetic sensors. Med Biol Eng Comput 2013; 51(4):377-86.
  3. Blue Cross and Blue Sheild Association Technology Evaluation Center (TEC). Gait analysis for pediatric cerebral palsy. TEC Assessments 2001; Volume 16, Tab 19.
  4. Dobson F, Morris ME, Baker R et al. Gait classification in children with cerebral palsy: a systematic review. Gait Posture 2007; 25(1):140-52.
  5. McGinley JL, Baker R, Wolfe R et al. The reliability of three-dimensional kinematic gait measurements: a systematic review. Gait Posture 2009; 29(3):360-9.
  6. Benedetti MG, Merlo A, Leardini A. Inter-laboratory consistency of gait analysis measurements. Gait Posture 2013; 38(4):934-9.
  7. Noonan KJ, Halliday S, Browne R et al. Interobserver variability of gait analysis in patients with cerebral palsy. J Pediatr Orthop 2003; 23(3):279-87.
  8. Wren TA, Otsuka NY, Bowen RE et al. Outcomes of lower extremity orthopedic surgery in ambulatory children with cerebral palsy with and without gait analysis: results of a randomized controlled trial. Gait Posture 2013; 38(2):236-41.
  9. Wren TA, Lening C, Rethlefsen SA et al. Impact of gait analysis on correction of excessive hip internal rotation in ambulatory children with cerebral palsy: a randomized controlled trial. Dev Med Child Neurol 2013; 55(10):919-25.
  10. Wren TA, Kalisvaart MM, Ghatan CE et al. Effects of preoperative gait analysis on costs and amount of surgery. J Pediatr Orthop 2009; 29(6):558-63.
  11. Lofterod B, Terjesen T, Skaaret I et al. Preoperative gait analysis has a substantial effect on orthopedic decision making in children with cerebral palsy: comparison between clinical evaluation and gait analysis in 60 patients. Acta Orthop 2007; 78(1):74-80.
  12. Lofterod B, Terjesen T. Results of treatment when orthopaedic surgeons follow gait-analysis recommendations in children with CP. Dev Med Child Neurol 2008; 50(7):503-9.
  13. Gough M, Shortland AP. Can clinical gait analysis guide the management of ambulant children with bilateral spastic cerebral palsy? J Pediatr Orthop 2008; 28(8):879-83.
  14. Schwartz MH, Rozumalski A, Truong W et al. Predicting the outcome of intramuscular psoas lengthening in children with cerebral palsy using preoperative gait data and the random forest algorithm. Gait Posture 2013; 37(4):473-9.
  15. Wren TA, Gorton GE, Ounpuu S et al. Efficacy of clinical gait analysis: a systematic review. Gait Posture 2011; 34(2):149-53.
  16. Suda Y, Saitou M, Shibasaki K et al. Gait analysis of patients with neurogenic intermittent claudication. Spine 2002; 27(22):2509-13.
  17. Sankar WN, Rethlefsen SA, Weiss J et al. The recurrent clubfoot: can gait analysis help us make better preoperative decisions? Clin Orthop Relat Res 2009; 467(5):1214-22.
  18. Asay JL, Boyer KA, Andriacchi TP. Repeatability of gait analysis for measuring knee osteoarthritis pain in patients with severe chronic pain. J Orthop Res 2013; 31(7):1007-12.
  19. Ferrarello F, Bianchi VA, Baccini M et al. Tools for observational gait analysis in patients with stroke: a systematic review. Phys Ther 2013; 93(12):1673-85.
  20. Schwenk M, Howe C, Saleh A et al. Frailty and technology: a systematic review of gait analysis in those with frailty. Gerontology 2014; 60(1):79-89.
  21. Sponsored by the Hospital for Sick Children. Outcomes of orthopedic surgery using gait laboratory versus observational gait analysis in children with cerebral palsy (NCT00419432). Available online at: www.clinicaltrials.gov. Last accessed January, 2014.

Coding Section

Codes Number Description
CPT See Policy Guidelines  
ICD-9 Procedure 93.09 Other diagnostic physical therapy procedures
ICD-9 Diagnosis 343.0-343.9 Infantile cerebral palsy code range
HCPCS No Code  
ICD-10-CM (effective 10/01/15) G80.0-G80.9 Cerebral palsy; code range
ICD-10-PCS (effective 10/01/15)   ICD-10-PCS codes are only used for inpatient services.
  4A0F33Z, 4A0FX3Z Measurement and monitoring, physiological systems, measurement, musculoskeletal, contractility, code by approach (percutaneous or external)
  F0101ZZ, F0111ZZ, F0121ZZ, F0131ZZ, F01D1ZZ, F01F1ZZ, F01G1ZZ, F01H1ZZ, F01J1ZZ, F01K1ZZ, F01L1ZZ, F01M1ZZ Rehabilitation, motor and/or nerve function assessment, integumentary integrity, code by body system/region
  F01ZDYZ, F01ZDZZ Rhabilitation, motor and/or nerve function assessment, gait and/or balance, codes for other equipment or no equipment
Type of Service Medical/Diagnostic  
Place of Service Inpatient/Outpatient  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

Index
Dynamic EMG
Electrodynagram
Gait Analysis
Motion Analysis
Surface EMG

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2013 Forward     

12/17/2020 

Annual review, no change to policy intent. 

12/12/2019 

Annual review, no change to policy intent. 

12/21/2018 

Annual review, no change to policy intent. 

12/20/2017 

Annual review, no change to policy intent. 

12/05/2016 

Annual review, no change to policy intent. 

11/5/2015 

Annual review, no change to policy intent. 

02/09/2015 

Fixed Formatting in Policy Section. No change to policy.  

12/01/2014 

Annual review, no change to policy intent. Added policy guidelines, key words, coding and benefit applications. Updated background, regulatory status, rationale and references. 

12/3/2013

Annual review.  Updated description, rationale and references. Added related policies.

 


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