CPT 95940, 95941, G0453 -Intraoperative Neurophysiologic Monitoring

Medically Necessary Code Description CPT

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) 

95941 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure)

HCPCS

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)

Reimbursement Guidelines - UHC

Per the American Medical Association Intraoperative Neuromonitoring (IONM) is the use of electrophysiological methods to monitor the functional integrity of certain neural structures during surgery. The purpose of IONM is to reduce the risk of damage to the patient’s nervous system and to provide functional guidance to the surgeon and anesthesiologist.

IONM codes are reported based upon the time spent monitoring only, and not the number of baseline tests performed or parameters monitored. In addition, time spent monitoring excludes time to set up, record, and interpret the baseline studies, and to remove electrodes at the end of the procedure. Time spent performing or interpreting the baseline neurophysiologic study(ies) should not be counted as intraoperative monitoring, as it represents separately reportable procedures.

According to The Centers for  Medicare and Medicaid Services (CMS) , Intraoperative neurophysiology testing (HCPCS/CPT codes 95940, 95941 and G0453) should not be reported by the physician performing an operative or anesthesia procedure since it is included in the global package.
The use of either modifier 26 or TC does not apply to codes 95940, 95941 or G0453.

The American Academy of Neurology states IONM services 95940, and 95941 should be performed in Place of Service (POS) 19,21, 22 or 24. Therefore,UnitedHealthcare will only reimburse 95940, 95941 and G0453 services when reported with POS 19, 21,22 and 24.


Questions and Answers

1Q: Will IONM services be reimbursed when reported with POS 15 (mobile unit)?

A :  No. Services furnished in a mobile unit are often provided to serve an entity for which another POS code exists. When this is the case, the POS for that entity should be reported. UnitedHealthcare will only allow reimbursement for IONM services when reported with POS 19, 21
, 22and 24

2Q:Are IONM codes with a status “I” allowed when reported in a facility setting?
A: No, per CMS guidance the status “I” code is not reimbursable. For more information please review other  reimbursement policies, including but not limited to the Replacement Codes Policy.

Continuous intraoperative neurophysiology monitoring: BCBS Guideline

codes 95940, 95941 and G0453 are considered incidental to the surgeon’s or anesthesiologist’s primary service and not eligible for separate  reimbursement when performed and billed by the surgeon or anesthesiologist. HCPCS Code G0453 will not be allowed when billed during the same operative session as 95940 or 95941.

Q. How many units of G0453 may be billed per hour? 

A.  Under Medicare, total billed units for G0453 for all Medicare patients may not sum to more than the total time available. For example, when  more than one 15-minute timed code is billed during a single  hour, then the total number of timed units that can be billed for that hour across all Medicare patients is constrained by 60 minutes, or 4 units of G0453. Physicians may use the method of their choice to allocate time to patients being simultaneously monitored subject to the above restriction (only one unit of service can be billed for a 15- minute increment of time).  The physician’s attention does not have to be continuous for a 15-minute block of time; the physician may add up any non-continuous time directed at one patient to determine how many units of G0453 may be billed

.  If Medicare and non -Medicare patients are being seen, physicians must account for the exclusive, non-continuous time spent monitoring Medicare patients when billing Medicare.


General CPT instructions for time d codes indicate that a unit of time is attained when the mid -point is passed. Medicare recognizes this CPT guidance for many timed codes, including G0453. Therefore, physicians may bill for one unit of G0453 if at least 8 minutes of service is provided as long as no more than 4 units of G0453 are billed for each 60 minutes


Intraoperative Neurophysiologic Monitoring

Introduction

Tests can be done on specific nerves during complex brain, spine, and neck surgeries to help make sure the nerves are not being harmed. This is known as intraoperative neurophysiologic monitoring (IONM). There are a number of ways to perform this monitoring. It often involves the use of sophisticated medical devices to assess the muscle or electrical response when a nerve is stimulated. The goal is to provide the surgeon with immediate feedback about whether a nerve is at risk of being injured. The surgeon can make a correction right away to avoid permanent damage. This type of monitoring is well proven in specific types of surgeries. Some surgeons are using IONM during surgery for nerves located outside of the brain and spinal cord (the peripheral nerves). There is not enough medical evidence to show whether IONM leads to better health results when used for the peripheral nerves. For this reason, IONM is considered not medically necessary for peripheral nerve surgery.

Note:   The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.


Intraoperative Monitoring

* Somatosensory-evoked potentials
* Motor-evoked potentials using transcranial electrical stimulation
* Brainstem auditoryevoked potentials
* Electromyography (EMG) of cranial nerves
* Electroencephalography * Electrocorticography
* EMG

Medical Necessity

The types of Intraoperative neurophysiologic monitoring, listed on the left, may be considered medically necessary when there is significant risk of nerve or spinal cord injury during the following spinal, intracranial, vascular or recurrent laryngeal nerve surgical procedures: (this list may not be all inclusive) *  Aortic, thoracic, and abdominal aneurysm repair * Aortic cross-clamping * Arteriovenous malformation repair of the spinal cord * Brachial plexus surgery * Cerebral vascular surgery (eg, carotid endarterectomy, cerebral  aneurysm) * Clipping of intracranial aneurysms * Cortical localization * Interventional neuroradiology * Pelvic fracture surgery * Release of a tethered cord * Repair of coarctation of the aorta * Resection of fourth ventricular cyst * Resection of intracranial vascular lesions * Resection of spinal cord tumor, cyst, or vascular lesion * Scoliosis correction with instrumentation * Surgical stabilization of spine fractures * Stereotactic surgery of the brain or brain stem, thalamus, or  cerebral cortex * Thalamus tumor resection or thalamotomy * Thyroid surgery * Anterior cervical spinal fusions * Thoracic spine surgery  Intraoperative neurophysiologic monitoring for ANY other indication, including during lumbar surgery below L1/L2 is considered not medically necessary. (see Related Information)  The types of intraoperative neurophysiologic monitoring,


Intraoperative Monitoring

* Nerve conduction velocity monitoring

Intraoperative Monitoring
* Somatosensory-evoked potentials
* Motor-evoked potentials using transcranial electrical stimulation
* Brainstem auditoryevoked potentials
* Electromyography (EMG) of cranial nerves
* Electroencephalography * Electrocorticography

Motor-evoked potentials using transcranial magnetic stimulation

Coding 

Medical Necessity

listed on the left during surgery on the peripheral nerves are considered not medically necessary.

Investigational

The types of intraoperative neurophysiologic monitoring, listed on the left during the following surgical procedure is considered investigational: * Esophageal surgeries

Due to the lack of monitors approved by the U.S. Food and Drug Administration, intraoperative monitoring of motorevoked potentials using transcranial magnetic stimulation is considered investigational.



Related Information 
 
These policy statements refer only to use of these techniques as part of intraoperative monitoring. Other clinical applications of these techniques, such as visual-evoked potentials and EMG, are not considered in this policy.

Intraoperative neurophysiological monitoring is indicated in select spine surgeries when there is risk for additional spinal cord injury. Intraoperative monitoring has not been shown to be of clinical benefit for routine lumbar or cervical nerve root decompression (AANEM 2014), or during routine lumbar or cervical laminectomy or fusion (AANEM, 1999a) in the absence of myelopathy or other complicating conditions, which could increase the potential risk of damage to the nerve root or spinal cord, Resnick et al (2005) in published guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine reported that based on the medical evidence of the literature reviewed there did not appear to be support for the hypothesis that any form of intraoperative monitoring improves patient outcomes following lumbar decompression or fusion procedures for degenerative spinal disease. The authors concluded in a 2014 update there was no evidence that intraoperative monitoring can prevent injury to the nerve roots.

Intraoperative neurophysiologic monitoring including somatosensory-evoked potentials and motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, electromyography of cranial nerves, electroencephalography, and electrocorticography has broad acceptance, particularly for spine surgery and open abdominal aorta aneurysm repairs. Additionally, this policy addresses monitoring of the recurrent laryngeal nerve during neck surgeries and monitoring of peripheral nerves.

Intra-operative monitoring is considered reimbursable as a separate service only when a licensed physician, other than the operating surgeon, performs the monitoring while in attendance in the operating room or present by means of a real-time remote mechanism and is immediately available to interpret the recording and advise the surgeon throughout the procedure.
Intra-operative monitoring consists of a physician monitoring not more than three cases simultaneously.

Constant communication between surgeon, neurophysiologist, and anesthetist are required for safe and effective intraoperative neurophysiologic monitoring.