Neurology & Pain Management Coding Alert

Neurologists performing intraoperative monitoring play a crucial role in many complex and delicate surgeries. Intraoperative monitoring allows physicians to ensure that the brain, spinal cord and other complex mechanisms and nerves are not compromised during a procedure. Coding for this service can also be a highly complex operation.

The CPT code for intraoperative monitoring is 95920 (intraoperative neurophysiology testing, per hour [list separately in addition to code for primary procedure]).
This is an add-on code that must be listed separately in addition to a primary procedure.

Neurologists May Not Be in the OR at All Times

Douglas M. Loop, CPA, administrator of Loma Linda University Neurology Associates, a 14-provider practice in Loma Linda, Calif., says that the neurologist usually is present at the beginning and end of surgery, personally ensuring that when the patient is going under and coming out of anesthesia that all the nerves are working normally. He or she also will monitor the movement of the extremities to ensure that they are moving properly. But the physical presence of the neurologist throughout a procedure is not always required. Often, a neurologist will have a technician remain on site to monitor the results while the neurologist is on call, available by pager or other means.

The neurologist may use remote video monitors to observe the surgery and monitor a readout at the same time. Also, a neurologist can use a laptop computer that is connected to the monitoring equipment so he or she can be mobile and still monitor the surgery from an off-site location. If problems arise, the neurologist can return to the operating room immediately.

The primary procedures fall into three categories, which Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pennsylvania Medical Center at Shadyside in Pittsburgh, and president of the American Association of Electrodiagnostic Medicine (AAEM), defines as follows:

1. Electroencephalogram (EEG): For examples, 95816 (electroencephalogram [EEG] including recording awake and drowsy [including hyperventilation and/or photic stimulation when appropriate]) and 95812 (electroencephalogram [EEG] extended monitoring; up to one hour)

2. EMG and Nerve Conduction Studies: For examples, 95860 (needle electromyography, one extremity with or without related paraspinal areas) and 95900 (nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study)

3. Evoked Potential Studies: For examples, 92585 (auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system) and 95925 (short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs)

Busis cites a carotid artery surgery (60605) as a prime example of EEG intraoperative monitoring. During this procedure, the EEG monitoring allows the neurologist to ensure that there is adequate circulation through the circle of Willis and to judge after the arteries are clamped above and below the operative area if a shunt will be required to create a blood flow detour. If there is a flux in the EEG after the clamps are put in place, the detour is deemed medically necessary. Otherwise, that part of the procedure may be avoided.

A central nerve conduction study may be used if the surgeon is teasing apart the brachial plexus (238.1), potentially to uncover a tumor. The surgeon needs to identify nerves so that he or she can perform the procedure with minimum of risk to the patients well- being. The neurologist stimulates the area on one side of the operating site and records the results from the other side. The feedback reveals the location of the nerves.

With evoked potentials like somatosensories, the neurologist stimulates the nerve in the arm or leg, and the progress of the signal into the spine, up the spinal cord, and into the brain is monitored. During a surgery for scoliosis (737.30), a somatosensory evoked potential study entails stimulation of the feet with recordings from the hand and other stations to determine if the spinal cord is being compromised in any way. If the waves indicated on the monitoring devices become distorted, a risk becomes apparent, and the surgeon immediately can pull back before any compromise is achieved.

Busis says that a baseline reading is taken prior to surgery with most forms of intraoperative monitoring so that the neurologist can compare the patients status before, during and after surgery.

Reasons for Delays or Denials

There are several state-to-state and carrier-to-carrier variations for properly billing intraoperative monitoring. The neurologist should check with his or her major carriers to learn of any state- or carrier-specific restrictions or requirements regarding billing for this service. For example, some carriers may have a limited list of acceptable diagnosis codes for certain procedures.

In California, Medicaid requires that the neurologist puts the start and stop times on the claims. If the neurologist does not do so, payments may be delayed. One common suggestion for billing for 95920 is that the intraoperative monitoring should never be the procedure that is listed first because it is an add-on code. The primary procedure that 95920 will be added onto must be listed above it.

Marc R. Nuwer, MD, PhD, of Los Angeles, a CPT advisor from the American Academy of Neurology, president of the International Federation of Clinical Neurophysiology, and professor of neurology at UCLA, states that The carriers are looking for times when the evoked potentials diminish and prolong or disappear entirely. Nuwer urges neurologists to send in a report along with the intraoperative monitoring. The carriers will look to see if there is a match from what is detailed in the report and what is billed. If the neurologist bills for four hours of monitoring, the carrier will look to see if the report bears out four hours worth of monitoring results. Loop also notes that he never reduces the charges of his service by adding modifier -52 (reduced services) to the
-26 modifier (professional component).

The full fee should always be billed out, Loop says. When a provider reduces her fee for an already reduced service, that can have an affect on her fee profileespecially for Medicare. Loop urges neurologists to let the carrier de-cide how great (if any) a reduction will be made to the fee.

The neurologist also should be clear about the place of service when filling out claims for intraoperative monitoring. The potential for denials in this regard is very high. If neurologists are performing intraoperative monitoring from any site outside the actual operating room, they should check with their carriers to determine how each expects to see the place of service coded. If the neurologist feels he or she is being asked to use a code other than the one that best describes the documented events, he or she should speak with a supervisor at the carriers office and get such requests in writing.