Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Intraoperative Neurophysiological Monitoring (INM)

Policy #:07.03.14n

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member’s contract.

MEDICALLY NECESSARY INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING (INM)

The quality, extent, and type of INM modality is dependent on the nature and location of the surgery. The following modalities for INM are considered medically necessary and, therefore, covered during vascular/cardiovascular, intracranial, endovascular, spine, orthopaedic, peripheral nerve, optic nerve, or otolaryngologic surgeries that may compromise neurophysiologic function as further outlined below:
  • Somatosensory-evoked potential (SSEP)
  • Motor-evoked potential (MEP) using transcranial electrical stimulation
  • Brainstem auditory-evoked potential (BAEP)
  • Neuromuscular junction (NMJ)
  • Electroencephalography (EEG)
  • Electrocorticography (ECoG)
  • Electromyography (EMG) and nerve conduction velocity (NCS)
  • Visual-evoked potential (VEP) to monitor the visual system during optic nerve (or related) surgery (monitoring of short-latency evoked potential studies)

INM is considered medically necessary and, therefore, covered when it is performed or supervised and interpreted by a professional provider (MD/DO) who is present at the operating site or from a remote location with real-time communication, monitoring of no more than one case at a time, and performed during one of the following procedures:

ENDOVASCULAR, VASCULAR/CARDIOVASCULAR SURGERY
  • Arteriography, during which there is a test occlusion of the carotid artery
  • Therapeutic embolization for aneurysm, arteriovenous malformation, or fistula
  • Transluminal angioplasty
  • Distal aortic procedures, in which there is a risk of ischemia to the spinal cord
  • Procedures requiring circulatory arrest with hypothermia (not including surgeries performed under circulatory bypass [e.g., coronary artery bypass or ventricular aneurysms])
  • Surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid artery surgery, when there is a risk of cerebral ischemia
  • Resection of carotid body tumor
  • Repair of cerebral vascular aneurysms

INTRACRANIAL SURGERY
  • Deep brain stimulation
  • Resection of brain tissue close to the primary motor cortex and requiring brain mapping
  • Clipping of intracranial anterior and posterior circulation aneurysm
  • Surgery for glomus jugulare tumor
  • Excision of posterior fossa tumor involving any motor cranial nerve, cranial nerve nuclei, or neural (motor/sensory) pathway
  • Resection of epileptogenic brain tissue or tumor
  • Surgery or embolization for intracranial arteriovenous malformations
  • Surgery for basal ganglia movement disorders
  • Surgery for intractable movement disorders
  • Surgery for intracranial tumor where there is risk of injury to brain vascular supplies
  • Surgery for decompression of posterior fossa for chiari malformation
  • Surgery requiring protection of cranial nerves, including the following procedures:
    • Surgery to correct tumors that affect optic, trigeminal, facial, or auditory nerves
    • Surgery to correct cavernous sinus tumors
    • Microvascular decompression of cranial nerves
    • Oval or round window graft
    • Endolymphatic shunt for Meniere's disease
    • Vestibular section for vertigo

SPINE SURGERY
  • Correction of scoliosis or deformity of the spinal cord involving traction on the cord
  • Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication where function of the spinal cord or spinal nerves and/or associated vascular supplies are at risk
  • Protection of the spinal cord where work is performed in close proximity to the cord as in the placement or removal of old hardware or where there have been numerous interventions
  • Excision of spinal cord or cauda equina tumors
  • Excision of primary or metastatic spinal tumor
  • Spinal instrumentation requiring pedicle screw anchoring or distraction where there is risk of injury to spinal cord or nerve roots
  • Surgery for spinal stabilization as a result of traumatic injury or disease to the spinal cord or the brain
  • Surgery for AV malformation of the spinal cord
  • Surgery for degenerative spinal disorders
  • Surgery for placement of spinal cord stimulator in the cervical or thoracic spine
  • Surgery for spinal dysraphism
  • Surgery for syringomyelia

ORTHOPAEDIC SURGERY
  • Leg-lengthening procedures, where there is traction on the sciatic nerve or other nerve trunks
  • Revision total hip replacement
  • Hip resurfacing
  • Repair of pelvic and acetabular fracture
  • Placement of sacroiliac screw fixation
  • Total arthroscopic shoulder repair
  • Open shoulder repair
  • Removal of first rib for management of thoracic outlet syndrome

PERIPHERAL NERVE SURGERY
  • Removal of neuromas of peripheral nerves of the brachial plexus, when there is a risk to major sensory or motor nerves
  • Brachial plexus reconstruction

OTOLARYNGOLOGIC SURGERY
  • Parotidectomy when there is risk of injury to the facial nerves and its branches
  • Thyroidectomy when there is a risk of injury to the recurrent and superior laryngeal nerves
    • Total removal of a complete lobe of the thyroid
    • Removal of the entire gland
    • Re-entry (re-operation) to a prior surgical field where scar tissue obscures the visual path of the recurrent laryngeal nerve
  • Radical or partial neck dissection
  • Revision of mastoidectomy
  • Tympanomastoidectomy
  • Translabyrinthine excision of acoustic neuroma
  • Vestibular nerve section
  • Facial nerve decompression
  • Repair of middle fossa cerebrospinal fluid leaks

The medical record must reflect that INM was requested by the operating surgeon and that it was performed,supervised, and interpreted by a professional provider other than the following:
  • The operating surgeon
  • A second physician acting as the technical/surgical assistant
  • The anesthesiologist rendering the anesthesia

EXPERIMENTAL/INVESTIGATIONAL INM

MODALITY USED FOR INM
MEP using transcranial magnetic stimulation for INM is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

SURGICAL USES FOR INM
All other surgical uses for INM is considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

NOT MEDICALLY NECESSARY INM

INM in situations where an individual's medical record and current practices reveal no potential for damage to neural integrity during surgery is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the treatment of illness or injury.

NON-REMOTE MONITORING

PROFESSIONAL PROVIDERS (MD/DO) PERFORMING OR SUPERVISING AND INTERPRETING NON-REMOTE INM
A professional provider (MD/DO) must meet the following criteria when performing or supervising technical personnel and interpreting non-remote INM:
  • Professional providers (MD/DO) must have knowledge and demonstrated expertise in INM in order to perform or supervise and interpret INM data.
  • The professional provider (MD/DO) must watch the tracings as they are obtained in real-time in the operating room, as well as the baseline electrophysiological test and monitoring tracings from earlier in the case.
  • The professional provider (MD/DO) for continuous INM in the operating room, must perform only one-on-one monitoring requiring personal attendance, for which undivided attention is directed to one individual (95940).

TECHNICIANS PERFORMING INM

A technician must be supervised by a professional provider (MD/DO) who has knowledge and demonstrated expertise in INM and must meet the following criteria when performing non-remote INM:
  • The technician who is performing INM must be under the direct supervision of a professional provider (MD/DO) who is in continuous attendance in the operating room, and must have knowledge and demonstrated expertise in INM.
  • The technician is in continuous attendance in the operating room.
  • Recording and monitoring is performed by the technician for a single surgical case.
  • Real-time physical or electronic capacity for communication exists with the professional provider (MD/DO) and the technician, operating surgeon, and anesthesiologist.

TECHNICAL CRITERIA
Technical criteria for non-remote INM must include all of the following criteria:
  • Eight available recording channels (16 if EEG is monitored) for all INM
  • The capability for the supervising professional provider (MD/DO) to observe the following monitor tracings:
    • Real-time in the operating room
    • Baseline electrophysiological test
    • Tracings from earlier in the case
  • The capability for continuous communications as needed between the supervising professional provider (MD/DO) and the monitoring technologist, operating surgeon, and anesthesiologist
  • Equipment that provides for the following monitoring modalities:
    • SSEP
    • MEP using transcranial electrical stimulation
    • BAEP
    • NMJ
    • EEG
    • ECoG
    • EMG and NCS

REMOTE MONITORING

PROFESSIONAL PROVIDERS (MD/DO) SUPERVISING AND INTERPRETING INM
A professional provider (MD/DO) must meet the following criteria when supervising technical personnel and interpreting remote INM:
  • The professional provider (MD/DO) is supervising no more than one case at a time.
  • The professional provider (MD/DO) must watch the tracings as they are obtained in real-time in the operating room, as well as the baseline electrophysiological test and monitoring tracings from earlier in the case.
  • In a remote location, real-time physical or electronic capacity for communication exists with the professional provider (MD/DO) and the technician, operating surgeon, and anesthesiologist.
  • The professional provider (MD/DO) for continuous INM from outside the operating room (remote or nearby), must perform only one-on-one monitoring requiring personal attendance, for which undivided attention is directed to one individual (G0453).

TECHNICIANS PERFORMING INM
A technician must be supervised by a professional provider (MD/DO) who has knowledge and demonstrated expertise in INM and must meet the following criteria when performing remote INM:
  • The technician who is performing INM must have knowledge and demonstrated expertise in INM.
  • The technician is in continuous attendance in the operating room.
  • Recording and monitoring is performed by the technician for a single surgical case.
  • Real-time physical or electronic capacity for communication exists with the professional provider (MD/DO) and the technician, operating surgeon, and anesthesiologist.

TECHNICAL CRITERIA
Technical criteria for remote INM must include all of the following criteria:
  • Eight available recording channels (16 if EEG is monitored) for all INM
  • The capability for the supervising professional provider (MD/DO) to observe the following monitor tracings:
    • Real-time in the operating room
    • Baseline electrophysiological test
    • Tracings from earlier in the case
  • Routine real-time auditory or written communication between the supervising professional provider (MD/DO) and the operating room
  • The capability for continuous telephone communication as needed between the supervising professional provider (MD/DO) and the monitoring technologist, operating surgeon, and anesthesiologist
  • Equipment that provides for the following monitoring modalities:
    • SSEP
    • MEP using transcranial electrical stimulation
    • BAEP
    • NMJ
    • EEG
    • ECoG
    • EMG and NCS

PROFESSIONAL REIMBURSEMENT

The Company considers the professional component of INM as the portion of the procedure or service performed by a professional provider that includes the supervision, interpretation, analysis, and a detailed signed written report of the results, as covered and eligible for reimbursement consideration as outlined in the applicable professional provider contract. Claims from professional providers for the technical component of INM are not eligible for reimbursement consideration.

FACILITY REIMBURSEMENT

The Company considers the technical component of INM, which includes the physical preparation, monitoring, reporting, and the equipment used, to be an inherent part of the payment provided to the facility for the surgical procedure and is, therefore, not eligible for separate reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Documentation of the performing provider's qualifications must be made available to Company upon request.
Guidelines

CLINICAL SPECIALIZATION PROGRAMS

Eligible providers performing, supervising, and interpreting INM should have knowledge and demonstrated expertise in INM. Competency to perform INM can be demonstrated through training from a clinical specialization program. Candidates are able to demonstrate their level of competence from a certification organization such as, but not limited to, the following:
  • The American Board of Clinical Neurophysiology, Inc. (ABCN)
  • American Board of Electrodiagnostic Medicine (ABEM)
  • The American Board of Neurophysiological Monitoring (ABNM)
  • The American Board of Psychiatry and Neurology's Added Qualifications in Clinical Neurophysiology (ABPN-CN)
  • The American Board of Registration of Electrodiagnostic Technologists (ABRET)
  • The American Society of Electroneurodiagnostic Technologists, Inc. (ASET)

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, intraoperative neurophysiological monitoring (INM) is covered under the medical benefits of the Company’s products when medical necessity criteria in this medical policy are met.

BILLING GUIDELINES

Time that is billed for INM should be submitted only for the time that was devoted to monitoring. Billed time should not exceed the amount of time that the individual was under anesthesia, which is reflected in the medical record. It may be cumulative but does not have to be continuous.

For medically necessary INM, a professional provider billing this service may code and bill for only one case at a time.

Description

Intraoperative neurophysiological monitoring (INM) refers to a variety of modalities that monitor the integrity of neural pathways during high-risk surgeries, including vascular/cardiovascular, intracranial, endovascular, spine, orthopaedic, peripheral nerve, optic nerve, and otolaryngologic surgeries. INM is distinct from clinical diagnostic studies. The primary objective of INM is to identify and prevent complications in the nervous system (the spinal cord or the brain), its blood supply, or adjacent tissue, with the expectation that prompt intervention will avert permanent deficits. The American Academy of Neurology (AAN) recommends that INM testing be reserved for surgical procedures in which there is a significant risk of damage to neural integrity.

INM can identify new neurologic impairment, identify or separate nervous system structures (e.g., around or in a tumor), and demonstrate which tracts or nerves are still functional. INM may provide a surgeon with confirmation that no identifiable complication has been detected up to a certain point. This allows the surgeon to proceed with a more thorough surgical intervention.

COMMON MODALITIES FOR INM

Several neurophysiological testing modalities are useful during INM. The quality, extent, and type of INM are dependent on the nature and location of the surgery.

SENSORY-EVOKED POTENTIAL TESTING
Sensory-evoked potential testing assesses the functional integrity of the central nervous system pathways during operations that put the spinal cord or brain at risk for significant ischemia or traumatic injury. The basic principles of sensory-evoked potential testing involve the identification of the neurological region at risk, the selection and stimulation (tactile, auditory, or visual) of a nerve that carries a signal through the region at risk, and the reading and interpretation of the signal at certain standardized points along the pathway.

The following sensory-evoked potential tests are considered for intraoperative monitoring:
  • Somatosensory-evoked potential (SSEP) testing: SSEP testing involves the stimulation of peripheral afferent nerves and the recording of signals from electrodes located on areas such as the scalp, spine, and epidural space. Intraoperative SSEP monitoring is indicated for select spine surgeries in which there is a risk of additional nerve root or spinal cord injury. However, according to the American Association of Electrodiagnostic Medicine (AAEM), intraoperative SSEP monitoring may not be indicated for routine lumbar or cervical root compression.
  • Brainstem auditory-evoked potential (BAEP) testing: BAEP testing involves auditory stimulation and recording of cortical responses from electrodes placed in various locations on the scalp. BAEP testing allows intraoperative monitoring of the function of the entire auditory pathway, including acoustic nerve, brain stem, and cerebral cortex. Other terms for this testing include brainstem auditory-evoked response (BAER), auditory-evoked potential (AEP), and auditory brainstem response (ABR).
  • Visual-evoked potential (VEP) testing: VEP testing records responses from visual pathway structures from the eyes to the occipital cortex of the brain. VEP testing has the potential utility of monitoring the integrity of visual pathway structures, including the optic nerves during surgery.

MOTOR-EVOKED POTENTIAL (MEP) TESTING
The standard modality of INM for spinal surgery is SSEP testing; however, significant motor deficits have been evident in individuals undergoing spinal surgery despite normal SSEP. Peer-reviewed literature reports that MEP testing, in combination with SSEP testing, improves the sensitivity and specificity of spinal cord monitoring. MEP testing is used to assess the descending motor pathways of the central nervous system. MEP is elicited by electrical or magnetic stimulation of the motor cortex or the spinal cord. Recordings are obtained as somatosensory pathways within the spinal cord or as myogenic potentials from the innervated muscle. MEP, especially when induced by magnetic stimulation, can be affected by anesthesia. The Digitimer electrical cortical stimulator received US Food and Drug Administration (FDA) premarket approval in 2002. Devices for transcranial magnetic stimulation have not yet received approval from the FDA for this use.

NEUROMUSCULAR JUNCTION (NMJ) TESTING
Repetitive stimulation studies are used to identify and differentiate disorders of the neuromuscular junction. NMJ testing consists of recording muscle responses to a series of nerve stimuli (at variable rates) both before and at various intervals after the transmission of high-frequency stimuli. During surgery, NMJ testing permits the administration of neuromuscular agents in clinical anesthesiology practice.

ELECTROENCEPHALOGRAPHY (EEG)
EEG measures and records electrical activity of the brain. During surgery, it is frequently used to assess gross cerebral blood flow.

ELECTROCORTICOGRAPHY (ECoG)
ECoG is the recording of the EEG directly from a surgically exposed cerebral cortex to define the sensory cortex and to map the critical limits of a surgical resection and to monitor for seizures during electrical stimulation of the brain.

ELECTROMYOGRAPHY (EMG) AND NERVE CONDUCTION VELOCITY (NCS)
EMG and NCS assess the status of the peripheral nerves and verify that the neural pathway is intact during surgery. EMG and NCS are frequently performed together and their results integrated into a unified study impression.
  • EMG evaluates the integrity of the functioning connection between a nerve and its innervated muscle, as well as the integrity of the muscle itself. The axon innervating a muscle is primarily responsible for the muscle's volitional contraction, survival, and trophic functions. Thus, interruption of the axon will alter the EMG.
  • NCS evaluates both motor and sensory nerve function. During NCS, a nerve is stimulated electrically to assess the speed (conduction velocity and/or latency), size (amplitude), and shape of the response.

CLINICAL SPECIALIZATION PROGRAMS

Competency to perform INM can be demonstrated through the completion of specialized training. Several organizations provide certification for clinical services at the professional or technical level related to performing INM. The following are examples of organizations that provide certification:
  • The American Board of Clinical Neurophysiology, Inc. (ABCN)
  • The American Board of Electrodiagnostic Medicine (ABEM)
  • The American Board of Neurophysiological Monitoring (ABNM)
  • The American Board of Psychiatry and Neurology's Added Qualifications in Clinical Neurophysiology (ABPN-CN)
  • The American Board of Registration of Electrodiagnostic Technologists (ABRET)
  • The American Society of Electroneurodiagnostic Technologists, Inc. (ASET)

NON-REMOTE MONITORING AND REMOTE MONITORING

In non-remote monitoring, INM may be performed by a professional provider (MD/DO) alone or by a technologist under the supervision of a professional provider (MD/DO) who has knowledge and demonstrated expertise in INM. The supervising professional provider (MD/DO) is in continuous attendance in the operating room and is able to give immediate feedback to the surgical team and anesthesiologist regarding the status of the neural integrity.

Advances in technology have made real-time data acquisition and transmission for interpretation possible. Remote INM involves a technician gathering data in the operating room while a supervising professional provider (MD/DO) interprets the data from a remote location, which may be in a monitoring room in the hospital setting or in an outside monitoring center, and gives instant feedback on the status of the neural integrity to the surgical team and anesthesiologist via real-time communication.

Due to the potential risk for morbidity, the beneficial results of INM are demonstrated with undivided attention to one unique individual at a time.

PROFESSIONAL AND TECHNICAL COMPONENTS OF INM

INM has both professional and technical components. The professional component of an INM service includes the supervision and the interpretation of the INM data. The supervision and interpretation of INM data is made by a professional provider (MD/DO) who has knowledge and a demonstrated expertise in INM.

The technical component of the INM includes the physical preparation (e.g., patient preparation), monitoring (e.g., operation of instrumentation for continuous neuromonitoring, establishing appropriate baselines), reporting (e.g., recognition and reporting of critical periods during surgery to a qualified professional provider, documentation), and the equipment used for INM. The technical component of the INM is performed by a technician who is certified through a clinical specialization program or who has completed a specialty training program and has demonstrated competency in the technical aspects of INM.
References


American Academy of Neurology. Evidence-based guideline update: intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) and the American Clinical Neurophysiology Society. Case presentation. [AAN Web site]. 2012. Available at:
https://www.aan.com/PressRoom/home/GetDigitalAsset/9285. Accessed May 09, 2018.

American Academy of Neurology (AAN). Principles of coding for intraoperative neurophysiologic monitoring (IOM) and testing model policy. [AAN Web site]. 02/10/12. Available at: http://patients.aan.com/globals/axon/assets/9339.pdf Accessed May 09, 2018.

American Association of Electrodiagnostic Medicine (AAEM). Position Statements. [AANEM Web site]. Available at: http://www.aanem.org/Advocacy/Position-Statements. Accessed May 09, 2018.

American Association of Electrodiagnostic Medicine (AAEM). Somatosensory evoked potentials: clinical uses. [AAEM Web site]. 09/08/1999. Available at:
https://www.aanem.org/getmedia/d26768d2-f94e-4939-9eb4-1a549e70a455/SEPClinicalUses.pdf Accessed May 09,2018.

American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Recommended policy for electrodiagnostic medicine. [AANEM Web site]. 08/30/2014. Available at: https://www.aanem.org/getmedia/ed2143b6-917f-4218-b699-e682b18ad15d/2014_Recommended_Policy_EDX_Medicine-(1).pdf Accessed May 09, 2018.

American Society of Neurophysiological Monitoring (ASNM). Accreditation & Certification. [ASNM Web site]. Available at:http://www.asnm.org/page/Certification. Accessed May 09, 2018.

American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS). Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 15: electrophysiological monitoring and lumbar fusion. J Neurosurg Spine. 2005;2(6):725-732.

American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS). Updated Position statement: intraoperative electrophysiological monitoring [AANS/CNS spine section Web site]. April 2014. Available at:http://www.spinesection.org/files/pdfs/IOM%20Position%20Statement%2004.24.2014.pdf. Accessed May 09, 2018.

Centers for Medicare and Medicaid Services. Billing Medicare for Remote Intraoperative Neurophysiology Monitoring in CY 2013. 12/17/12. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-Remote-IONM.pdf Accessed May 09, 2018.

Centers for Medicare and Medicaid Services. National Coverage Determination (NCD) 160.8 : Electroencephalographic monitoring during surgical procedures involving the cerebral vasculature. [CMS Web site]. 06/19/2006. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=77&ncdver=2&CoverageSelection=National&KeyWord=monitoring&KeyWordLookUp=Title&KeyWordLookUp=Title&KeyWordLookUp=Title&KeyWordSearchType=And&KeyWordSearchType=And&KeyWordSearchType=And&bc=gAAAACAAAAAA& Accessed May 09, 2018.

Chawla J. Motor evoked potentials. [eMedicine Web site]. 04/07/2016. Available at: http://emedicine.medscape.com/article/1139085-overview Accessed May 09, 2018.

Clarkson JH, Ozyurekoglu T, Mujadzic M et al. An evaluation of the information gained from the use of intraoperative nerve recording in the management of suspected brachial plexus root avulsion. Plast Reconstr Surg. 2011;127(3):1237-1243.

Isley MR, Edmonds HL Jr, Stecker M; American Society of Neurophysiological Monitoring (ASNM). Guidelines for intraoperative neuromonitoring using raw (analog or digital waveforms) and quantitative electroencephalography. a position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput. 2009;23(6):369-390.

Leppanen RE. Intraoperative monitoring of segmental spinal nerve root function with free-run and electrically triggered electromyography and spinal cord function with reflexes and f-responses. A position statement by the American Society of Neurophysiological Monitoring (ASNM). [ASNM Web site]. 2005. Available at: https://c.ymcdn.com/sites/www.asnm.org/resource/resmgr/Position_Statements/EMG_published.pdf Accessed May 09, 2018.

Liem LK. Intraoperative neurophysiological monitoring. [eMedicine Web site]. 03/17/16. Available at: http://emedicine.medscape.com/article/1137763-overview. Accessed May 09, 2018.

Macdonald DB, Skinner S, Shils J et al. Intraoperative motor evoked potential monitoring - A position statement by the American Society of Neurophysiological Monitoring. Clin Neurophysiol. 2013;124(12):2291-316.

Nagda SH, Rogers KJ, Sestokas AK et al. Neer Award 2005: Peripheral nerve function during shoulder arthroplasty using intraoperative nerve monitoring. J Shoulder Elbow Surg. 2007;16(3Suppl):S2-8.

National Institute for Health and Care Excellence (NICE). Intraoperative nerve monitoring during thyroid surgery. [NICE web site]. March 2008. Available at: https://www.nice.org.uk/guidance/ipg255 Accessed May 09, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD). (L34975): Neurophysiology Evoked Potentials (NEPs). [Novitas Solutions, Inc. Web site]. 04/07/2016. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34975. Accessed May 09, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35503: Intraoperative neurophysiological testing. [Novitas Solutions, Inc. Web site]. 04/12/2018. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35003&ver=43&Keyword=+Intraoperative+neurophysiological+testing.&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=SAD%7cEd&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAABABAAAA&. Accessed May 09, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L34996: Neuromuscular Junction Testing. [Novitas Solutions, Inc. Web site]. 10/01/2017. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34996&ver=17&Keyword=+Neuromuscular+Junction+Testing&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=SAD%7cEd&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAABABAAAA&. Accessed May 09, 2018.

Nuwer MR, Emerson RG, Falloway G, et al. Evidence-based guideline update: intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) and the American Clinical Neurophysiology Society. Neurology.2012;78(8):585-589.

Ochs BC, Herzka A, Yaylali I. Intraoperative neurophysiological monitoring of somatosensory evoked potentials during hip arthroscopy surgery. Neurodiagn J. 2012; 52(4):312-319.

Romstock J, Strauss C, Fahlbusch R. Continuous electromyography monitoring of motor cranial nerves during cerebellopontine angle surgery. J Neurosurg. 2000; 93(4):586-593.

Schwartz DM, Auerbach JD, Dormans JP, et al. Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am.2007; 89(11):2440-9.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

THE FOLLOWING CODE IS USED TO REPRESENT INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING (INM) REGARDLESS OF THE SPECIFIC TEST BEING PERFORMED:

95940

INM MODALITIES

51784, 51785, 92265, 92585, 92586, 95812, 95813, 95816, 95819, 95822, 95824, 95827 , 95830, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95874, 95885, 95886, 95887, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95925, 95926, 95927, 95930, 95937, 95938, 95950, 95951, 95953, 95954, 95955, 95956, 95957, 95958, 95961, 95962

THE FOLLOWING CODES ARE USED TO REPRESENT H-REFLEX STUDIES:

95907, 95908, 95909, 95910, 95911, 95912, 95913

THE FOLLOWING CODES ARE USED TO REPRESENT MEP USING TRANSCRANIAL ELECTRICAL STIMULATION:

95928, 95929, 95939

THE FOLLOWING CODE FOR INM DOES NOT MEET POLICY CRITERIA REFER TO G0453:

95941

EXPERIMENTAL/INVESTIGATIONAL

0333T

WHEN THE FOLLOWING CODES ARE USED TO REPRESENT MEP USING TRANSCRANIAL MAGNETIC STIMULATION ARE CONSIDERED EXPERIMENTAL/INVESTIGATIONAL

95928, 95929, 95939



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy.


HCPCS Level II Code Number(s)



THE FOLLOWING CODE IS USED TO REPRESENT REMOTE INM IN WHICH UNDIVIDED ATTENTION IS DIRECTED TO ONE PATIENT:

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)



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

07.03.14n
07/23/2018This version of the policy will become effective 07/23/2018. This policy has undergone a routine review, and removed thermal shoulder capsulorrhaphy as a medically necessary indication for INM.

07.03.14m
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT narrative has been revised in this policy:

95930

FROM: VISUAL EVOKED POTENTIAL (VEP) TESTING CENTRAL NERVOUS SYSTEM, CHECKERBOARD OR FLASH

TO: Visual evoked potential (VEP) checkerboard or flash testing, central nervous system except glaucoma, with interpretation and report


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 07/23/2018
Version Issued Date: 07/23/2018
Version Reissued Date: N/A

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