Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27499

Intraoperative Neurophysiological Testing

L27499

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Intraoperative neurophysiological testing may be used to identify/prevent complications during surgery on the nervous system, its blood supply, or adjacent tissue. Monitoring can identify new neurologic impairment, identify or separate nervous system structures (e.g., around or in a tumor) and can demonstrate which tracts or nerves are still functional. Intraoperative neurophysiological testing may provide relative reassurance to the surgeon that no identifiable complication has been detected up to a certain point, allowing the surgeon to proceed further and provide a more thorough or careful surgical intervention than would have been provided in the absence of monitoring. Monitoring, if used to assess sensory or motor pathways, should assess the appropriate sensory or motor pathways. Incorrect pathway monitoring could miss detection of neural compromise and has been shown to have resulted in adverse outcomes (1).

Some high-risk patients may be candidates for a surgical procedure only if monitoring is available.

Indications

Based on information in the scientific literature, intra-operative testing may be indicated for the following types of surgery:

• surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid artery surgery, when there is risk of cerebral ischemia
• resection of epileptogenic brain tissue or tumor
• resection of brain tissue close to the primary motor cortex and requiring brain mapping
• protection of cranial nerves:
  • tumors that affect optic, trigeminal, facial, auditory nerves
  • cavernous sinus tumors
  • microvascular decompression of cranial nerves
  • 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
• protection of spinal cord where work is performed in close proximity to cord as in the placement or removal of old hardware or where there have been numerous interventions
• spinal instrumentation requiring pedicle screws or distraction
• decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication where function of spinal cord or spinal nerves is at risk
• spinal cord tumors
• neuromas of peripheral nerves of brachial plexus, when there is risk to major sensory or motor nerves
• surgery or embolization for intracranial AV malformations
• surgery for arteriovenous malformation of spinal cord
• cerebral vascular aneurysms
• surgery for intractable movement disorders
• arteriography, during which there is a test occlusion of the carotid artery
• circulatory arrest with hypothermia [does not include surgeries performed under circulatory bypass (e.g., CABG, ventricular aneurysms)]
• distal aortic procedures, where there is risk of ischemia to spinal cord
• leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks
• basal ganglia movement disorders
• surgery as a result of traumatic injury to spinal cord/brain, and
• deep brain stimulation

Limitations

This test must be requested by the operating surgeon and the monitoring must be performed by a physician, other than:

• the operating surgeon;
• the technical/surgical assistant; or
• the anesthesiologist rendering the anesthesia.

The benefits of intraoperative neurophysiologic testing are attainable under optimal recording and interpreting conditions. The beneficial results of monitoring demonstrated by the 1995 multicenter study of this technique were realized under the following conditions in a hospital setting:

A well trained, experienced technologist was present at the operating site recording and monitoring a single surgical case.

A physician who is a trained clinical neurophysiologist (MD/DO) supervised the technologist and supervised no more than three cases simultaneously.

The surgical team and the monitoring staff were always in immediate contact. (2)

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 Board of Neurophysiologic Monitoring or the American Board of Registration of Electrodiagnostic Technologists will be in continuous attendance in the operating room, recording and monitoring a single surgical case, with either the physical or electronic capacity for real-time communication with the supervising neurologist or other physician trained in neurophysiology.

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.

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 (MD/DO). Technical criteria (mandatory) include that at least eight recording channels be available (16 if EEG is monitored) for all intraoperative neurophysiological monitoring. The remotely supervising physician must have the ability to watch the tracings as they are obtained in real-time in the operating room, as well as the baseline electrophysiological test and the monitoring tracings from earlier in the case.

Technical criteria (mandatory) for remote monitoring also include (a) routine real-time auditory or written communication between the supervising physician and the operating room and (b) the capability for telephone communications as needed between the supervising physician and the monitoring technologist, operating surgeon and the anesthesiologist.

The equipment must also provide for all of the monitoring modalities that may be applied with code 95920 - auditory-evoked response, electroencephalography/electrocorticography, electromyography and nerve conduction and somatosensory-evoked response.

Undivided attention to a unique patient may be required during some surgeries, such as during response to acute events or identification of the cerebral cortex to be resected or spared from resection. The monitoring physician must have a plan in place to transfer care to another physician of any other case during those times. When paying undivided attention to a unique patient, the physician must code and bill only for that one case during those times. For other medically necessary intraoperative neurophysiologic monitoring, a physician may code and bill for up to three cases simultaneously.

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 only for the time devoted to monitoring. 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.

Diagnostic Tests and X-Rays

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.

N/A

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
4. The medical record should support the time spent in monitoring and correlate to the surgery being performed.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Lesser, R. P., Raudzens, P., Luders, H., Nuwer, M. R., Goldie, W.D., Morris III, H. H., Dinner, D. S., Klem, G., Hahn, J.F., Shetter, A. G., Ginsburg, H. H., Gurd, A. R.  Postoperative neurological deficits may occur despite unchanged intraoperative somatosensory evoked potential.  Annals of Neurology, 1986; 19, 22-25.

Leung Y.L., Grevitt M., Henderson L., Smith J., Cord monitoring changes and segmental vessel ligation in the "at risk" cord during anterior spinal deformity surgery. Spine 2005; 30 (16): 1870-1874.

Nuwer, M. R., Dawson, E. G., Carlson, L. G., Kanim, L. E. A., Sherman, J. E.  Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery:  Results of a large multicenter survey.  Electroencephalography and Clinical Neurophysiology 1995; 96:6-11.

Principles of Coding for Intraoperative Neurophysiologic Monitoring (IOM) and Testing.
American Academy of Neurology Professional Association May, 2008

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27499

05/22/2008

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