Neurology & Pain Management Coding Alert

Have you got your intraoperative monitoring services coding under control? Maybe not, coding experts advise. If you're reporting only 95920, you could be losing out on hard-earned reimbursement.

Prior to performing intraoperative monitoring (+95920, Intraoperative neuro-physiology testing, per hour [list separately in addition to code for primary procedure]), the physician will conduct a "baseline study," which you may report separately and for which you should receive additional reimbursement. The neurologist must perform a baseline study to provide a basis for comparison during the monitoring. Intraoperative neurophysiological testing allows the physician to monitor the nervous system, its blood supply or adjacent tissue during surgery. Such monitoring can identify neurologic impairment, locate or separate nerve structures and determine which nerves remain functional, thereby allowing the operating surgeon to alter the surgery, if necessary, to avoid permanent neurological damage. Baseline studies may include auditory-evoked potentials (92585), sleep EEG (95822), EMG (95860-95861 and 95867-95868), nerve conduction studies (95900 and 95904) and evoked potentials (95925-95937), according to CPT. Individual carriers may also allow additional procedures, such as EEG (95812-95827, 95950-95954 and 95956) and central auditory testing (92589). You may report multiple baseline studies individually (for instance, if you perform both sleep EEG and an EMG, you may bill for each).

You should report intraoperative monitoring itself using 95920. This is an "add-on" code that must accompany the codes that describe the baseline studies, according to CPT guidelines. "CPT clearly indicates that you should not count the time spent performing or interpreting a baseline electrophysiologic study as intraoperative monitoring," says Tiffany Schmidt, JD, policy director for the American Association of Electro-diagnostic Medicine (AAEM). "Code 95920 includes only that time spent on ongoing electrophysiologic monitoring during surgery, with the baseline study billed separately" she says.

Keep in mind that code 95920 is time-based and billed "per hour," with each hour representing one "unit" (of time and reimbursement) on the CMS-1500 claim form. Convert time to increments of 0.5 units, in which the first 30 minutes equals 0.5 units, 60 minutes equals one unit, and so on, as follows:

Time         HCFA-1500

1-30 minutes 00.5

31-60 minutes 01.0

61-75 minutes 01.0

76-90 minutes 01.5

91-120 minutes 02.0, etc .

Always report only the actual time the physician spent on intraoperative monitoring. This must be time the physician spent actively monitoring the patient and does not include "standby time" in the operating room waiting for the surgery to begin, says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine. Although not all carriers request the information, physicians are advised to document the exact start and stop times.

You would not need to append modifier -51 (Multiple procedures) for multiple units of 95920.

You must append modifier -26 (Professional component) to 95920 and any baseline study codes anytime the neurologist provides these services in a facility setting, Busis says. Intraoperative monitoring code 95920, as well as all the codes that describe all baseline studies (for example, 95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study), includes both professional and technical components, according to the National Physician Fee Schedule Relative Value File. The physician must be present and interpreting the test results in "real time" (that is, during the surgery) to claim 95920, according to Medicare guidelines. Therefore, for Medicare payers, you should not claim separate reimbursement for any portion of 95920 if the physician interprets the results following surgery.

Always be sure to list the place of service when reporting intraoperative monitoring.

The neurologist does not need to be present in the operating room to provide intraoperative monitoring, according to Medicare carrier local medical review policies. 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 using digital transmission or closed-circuit television, the monitoring physician must have continuous or immediate contact with the operating surgeon so that he or she can instantly communicate any changes in the patient's status. If the neurologist is monitoring from outside the operating room, be sure to ask the insurer how to record the place of service.

If you're looking for more direction on billing intra-operative monitoring, consider the following example. A neurosurgeon requests that the neurologist provide monitoring during an aneurysm clipping. First, the neurologist provides a baseline EEG (95816), followed by a "monitoring" EEG in the operating room during the surgery to verify patient stability. The surgery begins at 4:00 p.m. and ends at 6:10 p.m. In this case, report 95816-26 for the baseline EEG and 95920-26 x 2 units (2 hours) for the intraoperative monitoring. Your accompanying documentation should note the start and stop times, as well as the neurologist's presence in the OR, Schmidt says.

In a second example, the neurologist uses somatosensory-evoked potentials (95926) to monitor a patient during spine surgery. The session lasts three hours, 55 minutes. In this case, Report 95926-26 and 95920-26 x 4 units, and you should provide all the necessary supporting documentation, as noted above.