L32491-LCD

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Local Coverage Determination (LCD) for Intraoperative Neurophysiology Testing (L32491)

Contractor Information Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L32491

LCD Title Intraoperative Neurophysiology Testing

Contractor's Determination Number A95920

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 06/12/2012 Original Determination Ending Date

Revision Effective Date

For services performed on or after 06/12/2012 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources: CMS On line Manual, Medicare Program Integrity Manual, Pub. 100-08, Chapter 13, Section 13.5.1

Indications and Limitations of Coverage and/or Medical Necessity

Intraoperative neurophysiology testing (IONT) 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 IONT 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.

IONT can be performed by a qualified technologist, neurologist, or other physician who has training in electrophysiology testing and the fundamentals of clinical neurophysiology. 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 testing 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). Currently, CPT code 95920 is a time based physician service and does not describe physician supervision of multiple patients simultaneously.

Medicare does not provide for reimbursement of “incident-to” care in the hospital setting for this service. The claims for physician services must be submitted for the medically reasonable and necessary time devoted to an individual patient by the testing physician. This time may be cumulative and does not have to be continuous. For example, one half hour of continuous attendance followed by another one half-hour later in the procedure will constitute one hour of testing. However, participating in two or more simultaneous surgeries may not meet the intent of the one-on-one physician testing described by CPT code 95920, given monitoring is not described by the code and is not a covered physician service. Therefore, two surgical procedures could have overlapping time related to start/stop times given the length of certain neurosurgical procedures, but the intraoperative neurophysiology testing time cannot be overlapped between the patients.

Coverage for IONT for the following types of surgery will be allowed:

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

• Resection of epileptogenic brain tissue or tumor

• 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

• Correction of scoliosis or deformity of spinal cord involving traction on the cord

• 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

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

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

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

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

• Embolization of bronchial artery AVMs or tumors

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

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

• Leg lengthening procedures when there is traction on the sciatic nerve

• Circulatory arrest with hypothermia

• 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 IONT, 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 testing physician is expected when medically indicated. 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 testing neurologist or other physician trained in neurophysiology. 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 testing and the procedure, Medicare does not expect to see operating surgeons or attending anesthesiologists submitting claims for this code.

Limitations of Coverage

IONT must be ordered by the operating surgeon, and the testing must be performed by a qualified physician who is other than:

• the operating surgeon,

• the technical/surgical assistant, or

• the anesthesiologist rendering the anesthesia

One-on-one testing 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 testing physician.

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

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

• The equipment must provide all testing modalities that may be applied with code 95920 – Auditory-evoked response, electroencephalography/electrocorticography, electromyography and nerve conduction, and somatosensory-evoked response.

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

Coding Information

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.

011x Hospital Inpatient (Including Medicare Part A)

012x Hospital Inpatient (Medicare Part B only)

Revenue Codes:

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.

0360 Operating Room Services - General Classification

0740 EEG (Electroencephalogram) - General Classification

0960 Professional Fees - General Classification

0975 Professional Fees - Operating Room

CPT/HCPCS Codes

95920 INTRAOPERATIVE NEUROPHYSIOLOGY TESTING, PER HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

ICD-9 Codes that Support Medical Necessity Inpatient only ICD-9 CM only procedure codes

00.94 Intra-operativeneurophysiologicmonitoring XX000 Not Applicable

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation supporting the need for IONT must be maintained in the patient's medical record and made available to the contractor upon request. 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 testing interval for which the physician provided one-on-one testing during the procedure. The total time billed to Medicare for one-on-one

testing for each patient must be supported in that patient’s record.

Appendices

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

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

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

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.

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. Advisory Committee Meeting Notes

Start Date of Comment Period 02/09/2012

End Date of Comment Period 03/24/2012

Start Date of Notice Period 04/27/2012

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:02/09/2012

Start Date of Notice Period:04/27/2012 Original Effective Date:06/12/2012

LCR A2012-042

April 2012 Connection

Reason for Change Narrative Change