Intraoperative neurophysiological monitoring is used to identify compromise to the nervous system during certain surgical procedures. Evoked responses are constantly monitored for changes that could imply damage to the nervous system. The intent of this monitoring is to alert the surgeon so the surgical procedure may be altered to avoid permanent neurological damage. Such impairments may be due to correctable factors such as circulatory disturbance, excess compression from retraction, bony structures or hematomas, or mechanical stretching. Monitoring can also identify new systemic impairment; identify or separate nervous system structures, e.g., around or in a tumor; and demonstrate which tracts or nerves are still functional.
Based on information in the scientific literature, it is recommended that coverage be provided for intraoperative neurophysiological testing for the following types of surgery. Additional procedures in which the nervous system is at risk for intraoperative injury will be considered with the submission of documentation supporting the medical necessity:
- 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.
- Endolymphatic 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 of peripheral nerves or brachial plexus when there is 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.
- Circulatory arrest with hypothermia.
- Distal aortic procedures when there is risk of ischemia to spinal cord.
- Leg lengthening procedures when there is traction on the sciatic nerve.
Due to the nature of these services and the potential for significant morbidity in some procedures requiring intraoperative monitoring, Medicare expects to see these services used in the inpatient setting only. As the level of anesthesia may significantly impact the ability to interpret intraoperative studies, continuous communication between the anesthesiologist and the monitoring physician is expected when medically indicated. It is also expected that a specifically trained technician, preferably 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 supervising 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 monitoring and the procedure, Medicare does not expect to see operating surgeons submitting claims for this code.
Monitoring may be performed from a remote site, as long as a trained technician (see detail above) will be in continuous attendance in the operating room, with either the physical or electronic capacity for real-time communication with the supervising physician. Technical criteria (mandatory) include 16-channel monitoring and minimum real-time auditory, with possible addition of video connectivity between monitoring staff, operating surgeon and anesthesia. The equipment must also provide for all of the monitoring modalities that may be applied with code 95920, that being auditory evoked response, electroencephalography/electrocorticography, electromyography and nerve conduction, and somatosensory evoked response. Undivided attention to a unique patient during the critical part of the surgery requiring the neuromonitoring is expected.
Medicare does not provide for reimbursement of “incident-to” care in the hospital setting. More than one patient may be monitored at once; however, claims for physician services must be submitted for the time devoted to each individual patient by the monitoring physician, i.e., not all patients simultaneously. This time, however, may be cumulative, and does not have to be continuous, i.e., one half hour of continuous attendance followed by another one half-hour later in the procedure will constitute one hour of monitoring. (Refer to the Coding Guidelines section in the related Article.)
See also “Neurophysiological Studies” LCD for coverage of other neurophysiological studies (CPT/HCPCS codes 95925, 95926, 95927, 95928, 95929 and 95930) and “Vestibular and Audiologic Function Testing” LCD for coverage of CPT/HCPCS codes 92585 and 92586.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
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.
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.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all the CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04 Claims Processing Manual for further guidance.
074X, 096X, 0975, 0982
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Intraop nerve test add-on
Unlisted neurological procedure
ICD-9-CM Codes that Support Medical Necessity
Not applicable at this time
Diagnoses That Support Medical Necessity
ICD-9-CM Codes That DO NOT Support Medical Necessity
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the appeal request.
Bill only for physician time. Bill each minute of the physician’s time once. If multiple patients are monitored simultaneously, bill with CPT code 95999.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Integration
TrailBlazer adopted, unchanged, the TrailBlazer LCD, “Intraoperative Neurophysiological Monitoring,” for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of information sources is found with original contractor LCD.
Other Contractor Local Coverage Determinations
“Intraoperative Neurophysiological Monitoring,” TrailBlazer LCD, (00400) L17137, (00900) L17139.
“Sensory Evoked Potentials & Intraop Neurophysiology Monitoring,” Noridian Administrative Services LLC LCD, (CO) L23842.