Indications and Limitations of Coverage and/or Medical Necessity
Based on information in the scientific literature, it is recommended that coverage be provided for intraoperative neurophysiological testing for the following types of surgery: (Note: 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)
1. Surgery of the aortic arch, its branch vessels, or thoracic aorta, including internal carotid artery surgery, when there is risk of cerebral ischemia.
2. Resection of epileptogenic brain tissue or tumor.
3. 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.
4. Vestibular section for vertigo.
5. Correction of scoliosis or deformity of spinal cord involving traction on the cord.
6. 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.
7. During placement of internal spinal fixation devices, i.e., pedicle screws where nervous system function is at risk.
8. Spinal cord tumors, and spinal fractures (with the risk of cord compression).
9. Neuromas of peripheral nerves or brachial plexus when there is risk to major sensory or motor nerves.
10. Surgery or embolization for intracranial arterio-venous malformations (AVMs).
11. Embolization of bronchial artery AVM's or tumors.
12. Arteriography during which there is a test occlusion of the carotid artery.
13. Circulatory arrest with hypothermia.
14. Distal aortic procedures when there is risk of ischemia to spinal cord.
15. 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 utilized in the inpatient setting only. As the level of anesthesia may significantly impact on 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 neurophysiologist. 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 neurologist or neurophysiologist. Technical criteria (mandatory) include 16-channel monitoring, 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.
CMS National Coverage Policy:
- Medicare Benefit Policy Manual - Pub. 100-2.
- Medicare National Coverage Determinations Manual - Pub. 100-3.
- Correct Coding Initiative - Medicare Contractor Beneficiary and Provider Communications Manual - Pub. 100-9, Chapter 5.
- Social Security Act (Title XVIII) Standard References:
- Section 1862 (a)(1)(A) Medically Reasonable & Necessary.
- Section 1862 (a)(1)(D) Investigational or Experimental.
- Section 1833(e) Sufficient documentation
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to Medicare upon request.
Bill only for physician time. Bill each minute of the physician's time once (e.g., if the physician monitors three patients for four hours, he may only bill for a grand total four hours, parsed between the three patients).
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