LCD/NCD Portal

L32489 INTRAOPERATIVE NEUROPHYSIOLOGY MONITORING

 

 

01/01/2013

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• IONM can be performed by a qualified technologist, neurologist, or other physician who has training in electrophysiology monitoring and the fundamentals of clinical neurophysiology.

o Though the intraoperative monitoring of a patient via a qualified MD/DO's direct supervision of a qualified technologist may be acceptable care in certain situations, MAC J9 only covers the medically reasonable and necessary time for one-on-one monitoring by the MD/DO (face to face by the qualified MD/DO in the operating room or via real-time recordings viewed by the MD/DO when a qualified technician is in continuous attendance in the operating room).

o Currently, CPT code 95940 and HCPCS code G0453 is a time based physician service and does not describe physician supervision of multiple patients simultaneously.

• Reimbursement is not provided for “incident-to” care in the hospital setting for this service.

o The claims for physician services must be submitted for the medically reasonable and necessary time devoted to an individual patient by the monitoring physician.

o This time may be cumulative and does not have to be continuous.

o For example, one half hour of continuous attendance followed by another one half-hour later in the procedure will constitute one hour of monitoring.

o However, participating in two or more simultaneous surgeries may not meet the intent of the one-on-one physician monitoring described by CPT code 95940 and HCPCS code G0453, given monitoring of multiple patients simultaneously is not described by the code and is not a covered physician service.

o Therefore, two surgical procedures could have overlapping time related to start/stop times given the length of certain neurosurgical procedures, but the intraoperative neurophysiology monitoring time cannot be overlapped between the patients.

• Coverage for IONM for the following types of surgery will be allowed:

o Surgery of the aortic arch, its branch vessels or thoracic aorta, including internal carotid artery surgery, when there is risk of cerebral ischemia.

o Resection of epileptogenic brain tissue or tumor.

o Protection of cranial nerves:

 Resection of tumors involving the cranial nerves.

 Microvascular decompressive surgeries (i.e., trigeminal neuralgia surgery).

 Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum.

 Cavernous sinus tumors.

 Oval or round window graft.

 Endolympatic shunt for Meniere's disease.

 Vestibular section for vertigo.

o Correction of scoliosis or deformity of spinal cord involving traction on the cord.

o Decompressive procedures on the spinal column or cauda equina performed for myelopathy or claudication where the function of spinal cord or spinal nerves is at risk.

o During placement of internal spinal fixation devices, i.e., pedicle screws where nervous system function is at risk.

o Spinal cord tumors and spinal fractures (with the risk of cord compression).

o Neuromas or tumors of peripheral nerves or brachial plexus when there is a risk to major sensory or motor nerves.

o Surgery or embolization for intracranial Arterio-Venous Malformations (AVMs).

o Embolization of bronchial artery AVMs or tumors.

o Arteriography during which there is a test occlusion of the carotid artery.

o Distal aortic procedures when there is risk of ischemia to spinal cord.

o Leg lengthening procedures when there is traction on the sciatic nerve.

o Circulatory arrest with hypothermia.

o During resection of cerebral lesion for the purpose of identifying and sparing eloquent structures (e.g. speech or motor cortex).

• Due to the nature of these services and the potential for significant morbidity in some procedures requiring IONM, these services are considered reasonable and necessary in the inpatient setting only.

• As the level of anesthesia may significantly impact the ability to interpret intraoperative studies, continuous communication between the anesthesiologist, operating surgeon(s) and the monitoring physician is expected when medically indicated.

o It is also expected that a specifically trained technician, registered with one of the credentialing organizations such as the American Society of Neurophysiologic Monitoring or the American Society of Electrodiagnostic Technologists, will be in continuous attendance in the operating room, with either the physical or electronic capacity for real-time communication with the monitoring neurologist or other physician trained in neurophysiology.

o Also, due to the potential risk for morbidity with many of the above-noted surgeries and the need for explicit and focused attention to both the monitoring and the procedure.

o It is not expected that operating surgeons or attending anesthesiologists would submit claims for this code.

 

 

Limitations of Coverage

 

• IONM must be ordered by the operating surgeon, and the monitoring must be performed by a qualified physician who is other than:

o the operating surgeon.

o the technical/surgical assistant.

o the anesthesiologist rendering the anesthesia.

• One-on-one monitoring may be performed from a remote site, ONLY if a trained technician is in continuous attendance in the operating room with either the physical or electronic capacity for real-time communication with the monitoring physician.

• Mandatory technical criteria include but are not limited to the following:

o 16-channel monitoring, minimum real-time auditory, with possible addition of video connectivity between monitoring staff, operating surgeon, and anesthesiologist.

o The equipment must provide all monitoring modalities that may be applied with code 95940 and G0453, Auditory-evoked response, electroencephalography/electrocorticography, electromyography and nerve conduction, and somatosensory-evoked response.

• IONM is not medically necessary in situations where historical data and current practices reveal no potential for damage to neural integrity during surgery.

o Monitoring under these circumstances will exceed the patient's medical need.

Credentials/Qualifications

• The neurologist, or other physician trained in neurophysiology, must have appropriate hospital staff privileges to perform services at the facility.

• A trained technician registered with one of the credentialing organizations such as the American Society of Neurophysiologic Monitoring or the American Society of Electrodiagnostic Technologists must be in continuous attendance in the operating room, with the physical or electronic capacity for real-time communication with the neurologist or other physician trained in neurophysiology

 

 

CPT/HCPCS Codes

 

95940 CONTINUOUS INTRAOPERATIVE NEUROPHYSIOLOGY MONITORING IN THE OPERATING ROOM, ONE ON ONE MONITORING REQUIRING PERSONAL ATTENDANCE, EACH 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

G0453 CONTINUOUS INTRAOPERATIVE NEUROPHYSIOLOGY MONITORING, FROM OUTSIDE THE OPERATING ROOM (REMOTE OR NEARBY), PER PATIENT, (ATTENTION DIRECTED EXCLUSIVELY TO ONE PATIENT) EACH 15 MINUTES (LIST IN ADDITION TO PRIMARY PROCEDURE)

 

 

Documentation Requirements

 

• Medical record documentation supporting the need for IONM must be maintained in the patient's medical record and made available to the contractor upon request.

o When the documentation does not establish the medical necessity, services will be denied as not reasonable and necessary under Section 1862(a) (1) of the Social Security Act.

• The patient’s medical record must indicate the start and stop time for every monitoring interval for which the physician provided one-on-one monitoring during the procedure.

o The total time billed to Medicare for one-on-one monitoring for each patient must be supported in that patient’s record.

 

 

Utilization Guidelines

 

• Only the physician time devoted to an individual patient should be billed, and each minute of the physician’s time should be billed once.

• IONM should not be reported by the physician performing the operative procedure since it is included in the global package for the surgery

 

 

Treatment Logic

 

• Intraoperative neurophysiology monitoring (IONM) is the use of electrophysiology methods to test the functional integrity of certain neural structures (e.g., nerves, spinal cord, and part of the brain) during certain surgeries.

• The principle goal of IONM is the identification of nervous system impairment in the hope that prompt intervention will prevent permanent deficits such as muscle weakness, loss of sensation, hearing loss, and impairment of other bodily functions, and/or to provide functional guidance to the surgeon and anesthesiologist.

• Secondly, the mapping techniques used to identify critical structures in the nervous system are identified electrophysiologically; the surgeon avoids these structures to prevent neurological damage from occurring.

• Correctable factors that can occur during surgery include circulatory disturbance, excess compression from retraction, bony structures or hematomas, or mechanical stretching.

 

 

Sources of Information and Basis for Decision

 

Dym, J., Hoh, D., Khalessi, A., Khoueir, P., Mundwiler, M., Jane, J., et al. (2008). Neurosurgical focus - Ankylosing spondylitis: physiology, pathology and surgical options. American Association of Neurological Surgeons, Vol. 24, 1.

 

FCSO LCD 32489, Intraoperative Neurophysiology Monitoring, 01/01/2013. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

LCDs and policies from other Medicare contractors and private insurers

 

Liem, L. & Benbadis, S. (2010). Intraoperative Neurophysiological Monitoring. Retrieved 01/05/2012 from: http://emedicine.medscape.com/article/1137763-overview

 

Principles of Coding for Intraoperative Neurophysiologic Monitoring (IOM) and Testing, Model Medical Policy. American Academy of Neurology, February 2012.

 

 

AMA CPT / ADA CDT Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

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