Neurology & Pain Management Coding Alert

Intraoperative neurophysiological testing monitors a patient for complications during surgery. Only one code (95920, intraoperative neurophysiology testing, per hour [list separately in addition to code for primary procedure]) is used to report this service, but receiving proper reimbursement is complicated by many regulations governing its use. Among these, add-on code 95920 must be listed with an appropriate primary procedure code, an acceptable diagnosis must accompany the claim, and  documentation and place-of-service guidelines must be met.

Intraoperative neurophysiological testing identifies and/or prevents complications during surgery on the nervous system, its blood supply or adjacent tissue. Such monitoring can identify neurologic impairment, locate or separate nerve structures, and determine which nerves remain functional. Evoked responses are monitored throughout the surgery for changes that may imply damage. According to Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, consultant and CPC trainer for A+ Medical Management and Education in Egg Harbor City, N.J, this allows the surgeon to alter the procedure, if necessary, to avoid permanent neurological damage and reduce the danger. In some cases, high-risk patients undergo surgery only if intraoperative testing is available.

Intraoperative monitoring is provided in addition to other electrophysiologic studies, e.g., electromyography (EMG), nerve conduction studies (NCS), or electroencephalograms (EEG), which establish a baseline for comparison during the surgery. According to CPT, 95920 describes ongoing electrophysiologic testing and monitoring during surgical procedures (regardless of the exact study performed), and includes only that time spent on ongoing electrophysiologic monitoring, says Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company. Time spent providing or interpreting baseline electrophysiologic study(ies) does not count toward intraoperative monitoring and should be reported separately.
 
CPT-listed baseline studies that may be billed in addition to 95920 include auditory-evoked potentials (92585), sleep EEG (95822), EMG (95860-95861 and 95867-95868), NCS (95900 and 95904) and evoked potentials (95925-95937). Individual carriers may allow additional procedures, however, such as EEG (95812-95827, 95950-95954 and 95956), and central auditory testing (92589).
 
Multiple baseline studies may be reimbursed individually, i.e., if both NCS and EMG are performed, each may be billed, Cobuzzi says, but report only one unit of 95920 per hour regardless of the number of electrophysiologic studies performed.
 
Always report the actual time (one unit of service per hour) spent on intraoperative monitoring (in the operating room, not "standby time"). The time should be reported in the appropriate "units" field according to the examples listed below.
 
Time       HCFA-1500
1-30 minutes  005
31-60 minutes  010
61-75 minutes  010
76-90 minutes  015
91-120 minutes  020

Note: Time is converted to increments of .5 units. The first (1-30 minutes) equals .5 units; 76-90 minutes equals 1.5 units, etc.
 
Although not all carriers request the information, it is wise to document the exact start and stop times. Modifier -51 (multiple procedures) is not required for multiple units of 95920. Some carriers will allow a maximum of two units of 95920 without justification for additional testing.
 
For example, the neurologist is called to provide intraoperative monitoring during an aneurysm clipping. A baseline EEG (95816) is performed, followed by a "monitoring" EEG during the surgery to verify patient  stability. The surgery begins at noon, lasting until 2:15 p.m. The session should be coded 95816, 95920 x 2 units. Accompanying documentation should note the exact start and stop times.
 
In a second example, the neurologist uses somatosensory-evoked potentials (95926) to monitor a patient during spine surgery. If the study shows that the spinal cord is compromised during surgery, the surgeon can react, Jandroep says. The session lasts three hours, 45 minutes. Report 95926, 95920 x 4 units. Again, documentation should include the exact start and stop times.
 
The Diagnosis Counts

To establish medical necessity, you must provide the appropriate diagnosis with all intraoperative monitoring claims. Carriers vary as to which ICD-9 codes they will accept, so it is wise to check into your carrier's guidelines prior to billing. A common list of approved diagnoses includes:

171.9 malignant neoplasm of connective and other soft tissue, site unspecified

192.1 malignant neoplasm of cerebral meninges

198.89 secondary malignant neoplasm of other specified sites

225.2-225.9 benign neoplasms

350.1 trigeminal neuralgia

721.90-721.91 spondylosis of unspecified site

722.51 degeneration of thoracic or thoracolumbar intervertebral disc

722.70-722.73 intervertebral disc disorder with myelopathy

723.0-724.09 spinal stenosis in cervical region

724.4 thoracic or lumbosacral neuritis or radiculitis, unspecified

737.30-737.34 kyphoscoliosis and scoliosis

754.2 congenital musculoskeletal deformities of spine

805.00-806.9 fracture of vertebral column with/without mention of spinal cord injury

952.00-952.9 cervical/thoracic spinal cord injury without evidence of spinal bone injury.

Place of Service

The neurologist does not need to be present in the operating room to provide intraoperative monitoring. Rather, he or she may be in the operating room suite or at a remote site with the monitoring performed using digital transmission or closed-circuit television. However, when digital transmission or closed-circuit television is used, there must be a provision for continuous or immediate contact with the operating surgeon to ensure that any changes in the patient's status can be immediately communicated. Always list the place of service. If the neurologist is monitoring from outside the operating room, he or she should ask the insurer how the place of service should be noted.