Principles of Coding for Intraoperative Neurophysiologic


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Principles of Coding for Intraoperative Neurophysiologic Monitoring (IOM) and Testing1
American Academy of Neurology
Model Medical Policy
Background
Intraoperative neurophysiologic monitoring (IOM) and testing are medical procedures that have been in standard practice for almost 30 years. The procedures allow monitoring of neurophysiologic signals during a surgical procedure whenever the neuroaxis is at risk as a consequence of either the surgical manipulation or the surgical environment. IOM is an umbrella monitoring term and includes electroencephalography (EEG), cranial nerve evoked potentials (EPs), brain-stem auditory EPs (BAEPs), motor EPs (MEP), somatosensory EPs (SEP), nerve conduction, and electromyography (EMG) signals. Much like the other instrumental clinical monitoring technologies, such as cardiac or capnic monitoring, randomized controlled trials establishing efficacy of IOM have not been done. Current best data, accumulated over the past two decades, have been derived through comparisons with historical controls and in the number of complications avoided through IOM. Difficulties in procedural blinding would impede accumulation of randomized controlled data. This status is not unlike that of intraoperative transesophageal echocardiography (TEE) or perioperative echocardiography (POE), two other widely-endorsed monitoring technologies (Memtsoudis et. al., 2006, Ng 2009). Both neurophysiologic IOM and TEE/POE are recognized medical practice standards reliant on experience, case series and retrospective analyses.
IOM is of value in surgeries at diverse locations. The types of diseases for which monitoring is helpful also vary. For instance IOM may be necessary for carotid endarterectomies, removal of cortical-hemispheric lesions, extirpation of epileptic foci, brain stem surgeries, spinal corrections and peripheral nerve repairs to name some examples. IOM is used in neurosurgery, orthopedic, vascular, cardiothoracic and other surgical specialties. A compilation of recent reviews for these various areas is available (Nuwer, 2008). This policy addresses only surgical intraoperative monitoring and does not address monitoring performed in radiologic suites. The quality, extent and type of monitoring are dependent on the nature and location of the lesions. The utility of monitoring is exquisitely reliant on the rigors of the monitoring procedure and protocols, and the clinical expertise of the monitoring physician. We list below several significant instances each of which has independently demonstrated the value of IOM in averting neural injuries during surgery.
1 Approved by the AAN Board of Directors on February 10, 2012; replaces previous AANPA policy (2010-12).
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1. Value of EEG Monitoring in Carotid Surgery Carotid occlusion, incident to carotid endarterectomies, poses a high risk for cerebral hemispheric injury. EEG monitoring is capable of detecting cerebral ischemia, a serious prelude to injury. Studies of continuous monitoring established the ability of EEG to correctly predict risks of postoperative deficits after a deliberate, but necessary, carotid occlusion as part of the surgical procedure (Redekop & Ferguson, 1992; Cloughesy et al., 1993; Woodworth et al., 2007). The surgeon can respond to adverse EEG events by raising blood pressure, implanting a shunt, adjusting a poorly functioning shunt, or performing other interventions.
2. Multicenter Data in Spinal Surgeries An extensive multicenter study conducted in 1995 demonstrated that IOM using SEP reduced the risk of paraplegia by 60% in spinal surgeries (Nuwer et al., 1995). The incidence of false negative cases, wherein an operative complication occurred without having been detected by the monitoring procedure, was small: 0.06% (Nuwer et al., 1995).
3. Technology Assessment of Monitoring in Spinal Surgeries A technology assessment by the McGill University Health Center (Erickson et al., 2005) reviewed 11 studies and concluded that spinal IOM is capable of substantially reducing injury in surgeries that pose a risk to spinal cord integrity. It recommended combined SEP/MEP monitoring, under the presence or constant availability of a monitoring physician, for all cases of spinal surgery for which there is a risk of spinal cord injury.
4. Value of Combined Motor and Sensory Monitoring Numerous studies of post-surgical paraparesis and quadriparesis have shown that both SEP and MEP monitoring had predicted adverse outcomes in a timely fashion (Schwartz et al., 2007; Lee et al., 2006; Nuwer et al., 1995; Jones et al., 2003; Meyer et al., 1988; Pelosi et al., 2002; Hilibrand et al., 2004; Langeloo et al. 2003; Mostegl et al. 1988; Eggspuehler et al 2007; Leung et al. 2005; Khan et al., 2006; Sutter et al., 2007; Weinzieri et al., 2007). The timing of the predictions allowed the surgeons the opportunity to intervene and prevent adverse outcomes. The two different techniques (SEP and MEP) monitor different spinal cord tracts. Sometimes, one of the techniques cannot be used for practical purposes, for anesthetic reasons, or because of pre-operative absence of signals in those pathways. Thus, the decision about which of these techniques to use needs to be tailored to the individual patient’s circumstances.
5. Protecting the Spinal Cord from Ischemia during Aortic Procedures Studies have shown that IOM accurately predicts risks for spinal cord ischemia associated with clamping the aorta or ligating segmental spinal arteries (MacDonald & Janusz, 2002; Jacobs et al., 2000; Cunningham et al., 1987; Kaplan et al., 1986; Leung et al., 2005). IOM can assess whether the spinal cord is tolerating the degree of relative ischemia in these procedures. The surgeon can then respond by raising blood pressure, implanting a shunt, re-implanting segmental vessels, draining spinal fluid, or through other interventions.
6. Common Types of Alerting Events Observed During Monitoring Another recent study (Lee et al., 2006) described types of neurophysiologic alerts and correlated them with postoperative neurological deficits that occurred during the course of 267 procedures involving anterior cervical spine surgery utilizing EMG, transcranial electrical motor and somatosensory evoked potential monitoring. In this study, 18.4 % of cases resulted in at least
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one intraoperative neurophysiologic alert; and major alerts believed to be related to specific intraoperative surgical maneuvers were identified in 4.6% of the patients monitored. In 88% of the patients with relevant amplitude loss that was thought to be related to the surgical procedure, the signal response returned once appropriate intraoperative corrective measures were taken.
7. Value of EMG Monitoring Selective posterior rhizotomy in cerebral palsy significantly reduces spasticity, increases range of motion, and improves functional skills (Staudt et al., 1995). Electromyography during this procedure can assist in selecting specific dorsal roots to transect. EMG can also be used in peripheral nerve procedures that pose a risk of injuries to nerves (Nuwer, 2008).
8. Futility of Monitoring Inappropriate Pathways In order to be useful, monitoring should assess the appropriate sensory or motor pathways. Incorrect pathway monitoring could miss detection of neural compromise. Examples of “wrong pathway” monitoring have been shown to have resulted in adverse outcomes (Lesser et al., 1986).
9. Value of Spinal Monitoring using SSEP and MEPs According to a recent review of spinal monitoring using SSEP and MEPs by the Therapeutics and Technology Assessment Subcommittee of the AAN and the American Clinical Neurophysiology Society, IOM is established as effective to predict an increased risk of the adverse outcomes of paraparesis, paraplegia, and quadriplegia in spinal surgery (4 Class I and 7 Class II studies) (Nuwer et al., 2012). Surgeons and other members of the operating team should be alerted to the increased risk of severe adverse neurologic outcomes in patients with important IOM changes (Level A).
Neurophysiologic Techniques Used in IOM
Several neurophysiologic testing modalities are useful during IOM. The location and type of surgery determine the chosen testing modality. The tests and codes listed here may be used individually or in combination.
 Electroencephalography (EEG); o With direct physician supervision, use codes 95822 plus 95920 o With general physician supervision, use code 95955
 Electrocorticography (ECoG); o Use code 95829
 Direct cortical stimulation to localize function; o Use codes 95961, 95962
 Deep brain stimulation electrode placement o Use codes 95961, 95962
 Pallidotomy site testing; o Use codes 95961, 95962
 Somatosensory evoked potential (SEP) monitoring o Use codes 95925, 95926, and/or 95927 plus 95920
 Intraoperative SEP identification of the sensorimotor cortex
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o Use codes 95925 and/or 95926 plus 95920  Motor evoked potentials (MEP)
o Use codes 95928 and/or 95929 plus 95920  Mapping the descending corticospinal tract
o Use codes 95928 and/or 95929 plus 95920  Brainstem auditory evoked potentials
o Use code 92585 plus 95920  Peripheral nerve stimulation and recording
o Use codes 95900 and/or 95904 plus 95920  Oculomotor, facial, trigeminal and lower cranial nerve monitoring
o Use codes 95867, 95868 and/or 95933 plus 95920  EMG monitoring and testing of peripheral limb pathways
o Use codes 95861, 95862 or 95870 plus 95920  Pedicle screw stimulation
o Use codes 95861, 95862 or 95870 plus 95920  Selective dorsal rhizotomy rootlet testing;
o Use codes 95861, 95862 or 95870 plus 95920  Transcranial electrical MEPs (tceMEPs) for external anal and urethral sphincter muscles
monitoring. o Use code 95870 plus 95920
Limitations on Coverage
To derive optimal benefits from this technology it is incumbent on the IOM team to understand the limits of the technology, listed below.
1. Use of Qualified Personnel IOM must be furnished by qualified personnel. For instance, the beneficial results of monitoring with SSEPs demonstrated by the 1995 multicenter study (Nuwer et al., 1995) showed fewer neurological deficits with experienced monitoring teams. While false positive events were significant in only 1% of cases, the negative predictive value for this technique was over 99%. Thus, absence of events during monitoring signifies and assures safety of the procedure. In general it is recommended that the monitoring team strive to optimize recording and interpreting conditions such that:
 A well-trained, experienced technologist, present at the operating site, is recording and monitoring a single surgical case; and
 A monitoring clinical neurophysiologist supervises the technologist.
2. Effects of the Depth of Anesthesia and Muscle Relaxation The level of anesthesia may also significantly impact on the ability to interpret intraoperative studies; therefore, pre-operative planning and continuous communication between the anesthesiologist and the monitoring team is expected.
3. Recording Conditions It is also expected that a specifically trained technologist or non-physician monitorist, preferably with credentials from the American Board of Neurophysiologic Monitoring or the American
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Board of Registration of Electrodiagnostic Technologists (ABRET), will be in continuous attendance in the operating room, with either the physical or electronic capability for real-time communication with the supervising physician.
4. Monitoring Necessity Intraoperative monitoring is not medically necessary in situations where historical data and current practices reveal no potential for damage to neural integrity during surgery. Monitoring under these circumstances will exceed the patient’s medical need (Social Security Act (Title XVIII); Medicare Benefit Policy Manual).
5. Communications Monitoring may be performed from a remote site, as long as a well-trained technologist (see detail above) is in continuous attendance in the operating room, with either the physical or electronic ability for prompt real-time communication with the supervising monitoring physician.
6. Supervision Requirements Different levels of physician supervision apply to different kinds of IOM procedures. Code 95920 supervision requires continuous physician monitoring which can be provided online or in the operating room (OR). Codes 95961-95962 (Functional cortical localization with brain stimulation) require personal physician supervision in the OR.
Use of 95920 and its Base Procedure Codes
1. IOM is a procedure that describes ongoing electrophysiologic testing, and monitoring performed during surgical procedures. It includes only the time spent during an ongoing, concurrent, real time electrophysiologic monitoring.
2. Time spent in activities other than those above should not be billed under 95920. The time spent performing or interpreting the baseline electrophysiologic studies should not be counted as intra-operative monitoring, but represents separately reportable procedures.
For example, 95920 is distinct from performance of specific types of pre-procedural baseline electrophysiologic studies (95860, 95861, 95867, 95868, 95900, 95904, 95933, 95934, 95936, 95937) or other interpretation of specific types of baseline electrophysiologic studies (95985, 95922, 95925, 95928, 95927, 95928, 95929, 95930).
The supervising physician time spent in the operating room includes the time from entering until leaving the operating room, except for the time spent interpreting the baseline testing. For remote monitoring, it includes time from initiating to discontinuing monitoring except for the time spent interpreting the baseline testing.
3. Note that the supervision requirements for each underlying test or primary test modality vary, and must be met (Medicare Benefit Policy Manual).For example, cortical mapping during monitoring requires personal supervision.
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4. Code 95920 should not be reported by the surgeon or anesthesiologist performing an operative procedure, since it is included in the global package if they serve as the IOM supervising physician. Code 95920 is bundled into most surgeries by National Correct Coding Initiative edits. The surgeon performing an operative procedure should not bill other 90000 series neurophysiology testing codes for intraoperative neurophysiology testing (e.g., 92585, 95822, 95860, 95861, 95867, 95868, 95870, 95900, 95904, 95925-95937) since they are also included in the global package (Medicare Benefit Policy Manual). However, when IOM or baseline procedures are performed by a different, monitoring physician during the procedure, it is separately reportable by the monitoring supervising physician. 5. Code 95920 is performed in the hospital setting. Monitoring of a patient with code 95920 should use Hospital site of service (site 21), or Hospital Outpatient surgery center (site 22), even if the monitoring physician is located in an office. When supervising and interpreting IOM on a hospitalized patient, the supervising physician codes using modifier -26. 6. One or more simultaneous cases may be reported without division of time between them. The number of cases monitored at any one time will vary, but should not exceed the requirements for providing adequate attention to each. For example, a 2010 AAN survey of IOM practitioners shows that on average 90% of monitoring hours are spent monitoring three (3) or fewer simultaneous cases and that practitioners rarely monitor more than six (6) cases simultaneously (AAN Survey of IOM Practitioners 2010 – unpublished).
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CPT/HCPCS Codes

AMA CPT® Copyright Statement: CPT codes, descriptions, and other data are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

95920 Intraoperative neurophysiology testing, per hour (List separately in addition to base code for primary procedure)

Codes for primary procedures used as base codes for 95920

92585
95822 95860 95861 95867 95868 95870
95900
95904 95925
95926
95927
95928 95929 95930 95933 95934 95936
95937
95938
95939

Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive Electroencephalogram (EEG); recording in coma or sleep only Needle electromyography; one extremity with or without related paraspinal areas Needle electromyography; two extremities with or without related paraspinal areas Needle electromyography; cranial nerve supplied muscle(s), unilateral Needle electromyography; cranial nerve supplied muscles, bilateral Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without Fwave study Nerve conduction, amplitude and latency/velocity study, each nerve; sensory Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head Central motor evoked potential study (transcranial motor stimulation); upper limbs Central motor evoked potential study (transcranial motor stimulation); lower limbs Visual evoked potential Orbicularis oculi (blink) reflex, by electrodiagnostic testing H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle H-reflex, amplitude and latency study; record muscle other than gastrocnemius/soleus muscle Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs

Use of Other Procedure Codes for Intraoperative Monitoring and/or Testing Implanted Device Neurophysiology Codes
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Codes for use with implanted devices (95961, 96962, 95970-95979) Two series of codes are used to locate the proper sites for deep brain or spinal cord implanted devices and to test the device’s integrity.

Codes 96961 (first hour) and 96962 (additional hours) are used for intraoperative testing of electrode placement. Code 95970 is used to check a device’s integrity. Rarely, the devices are also programmed while in the operating room, and when done those services are coded using 95971 through 95979. These codes are:

95970 95971 95972 95973 95974 95975 95978

Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure) Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure) Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and

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95979

patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; each additional 30 minutes after first hour (List separately in addition to code for primary procedure)

Functional Cortical Mapping Codes 95829 Electrocorticogram at surgery (separate procedure) 95961 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes
on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance 95962 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional hour of physician attendance (List separately in addition to code for primary procedure)

Three codes are used in the operating room to locate abnormal regions or regions that serve key brain functions. This includes the electrocorticography (ECoG) code 95829, which is used to record EEG directly from the exposed brain. This is used to find areas of cortex that are damaged or that may be the source of epileptic seizures. This also includes the functional cortical stimulation codes 95961 (first hour) and 95962 (additional hours). Most often those codes are used when the brain is stimulated electrically and the results are monitored behaviorally in a patient who is awake during neurosurgery. These guide the surgeon as to which portions of the exposed brain could or should be removed or which should be preserved.

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Appendix A – Diagnoses that Support Medical Necessity

Note: All ICD-9-CM codes listed below may be viewed as medically necessary; however, there may be other diagnostic codes not included in this list that are deserving of consideration for coverage. Such instances may require individual consideration.

015 170 170.2 191.9 192.0 192.1 192.2 192.3 192.8 192.9 198.3 198.4 198.5 213 213.2 225.0 225.1 225.2 225.2 225.3 225.4 225.8 225.9 228.02 237.0 237.1 237.3 237.5 237.6 237.70 237.71 237.72 237.9 239.6 324.0 324.1 324.1 324.9 336.0

Spinal tuberculosis Malignant temporal bone Malignant neoplasm of vertebral column excluding sacrum and coccyx Malignant neoplasm of brain unspecified site Malignant neoplasm of cranial nerves Malignant neoplasm of cerebral meninges Malignant neoplasm of Spinal cord Malignant neoplasm of Spinal meninges Malignant neoplasm of other specified sites of nervous system Malignant neoplasm of nervous system part unspecified Secondary malignant neoplasm of brain and Spinal cord Secondary malignant neoplasm of other parts of nervous system Metastatic disease to thoracic, lumbar and cervical spinal column Temporal bone lesion Benign neoplasm of vertebral column excluding sacrum and coccyx Benign neoplasm of brain Benign neoplasm of cranial nerves Benign neoplasm of cerebral meninges Meningioma Benign neoplasm of Spinal cord Benign neoplasm of Spinal meninges Benign neoplasm of other specified sites of nervous system Benign neoplasm of nervous system part unspecified Intracranial hemangioma Neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct Neoplasm of uncertain behavior of pineal gland Glomus tumor Neoplasm of uncertain behavior of brain and Spinal cord Neoplasm of uncertain behavior of meninges Neurofibromatosis unspecified Neurofibromatosis type 1 von recklinghausen's disease Neurofibromatosis, type 2 (acoustic neurofibromatosis) Neoplasm of uncertain behavior of other and unspecified parts of nervous system Neoplasm of unspecified nature of brain Intracranial abscess Intraspinal abscess Intraspinal abscess Intracranial and intraspinal abscess of unspecified site Syringomyelia and syringobulbia

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Principles of Coding for Intraoperative Neurophysiologic