Neurology & Pain Management Coding Alert

Question: I am wondering if you have any information about coding and reimbursement for intra-operative monitoring of thyroidectomy cases.-We have a neurologist in our practice who does many of these cases and we receive denials from Medicare and other carriers because of the diagnosis. Do you have any information that might be of assistance to us?

New York Subscriber

Answer: Your denials are most likely driven by payer coverage policies. The diagnosis reported probably does not meet the payer's medical necessity criteria.-Many payers do not include the typical diagnoses for thyroid or radical neck dissection surgeries as medically necessary for intraoperative monitoring or the baseline diagnostic studies, such as somatosensory evoked potentials (SSEP), motor evoked potential (MEP), electromyogram (EMG), etc.-These diagnostic studies-are reported as the "parent" or "primary" code(s) for the add-on intraoperative monitoring code, +95920 (Intraoperative neurophysiology testing, per hour [List separately in addition to code for primary procedure]).

Best bet: Check your Medicare contractor's Web site for specific information on intraoperative monitoring coverage policies.-As with any Medicare-local coverage determination (LCD) policy,-if the services are provided for a diagnosis -- an ICD-9 code -- that-is not included in the policy list as supporting medical necessity, the patient must be informed prior to receiving the service-of-the potential for non-coverage. The patient must have an opportunity-to make an informed decision as to whether she wants to have the services and potentially be responsible for the service.

If the-patient decides to proceed, your provider should have the patient sign an advance beneficiary notice (ABN) acknowledging she agrees to have the service performed and will be responsible if not covered by Medicare.-Report the services to Medicare with the GA modifier (Waiver of liability statement on file) appended to the CPT codes indicating that the provider has a signed ABN form on file for this service.-If the service is indeed not covered due to medical necessity, the GA modifier will allow Medicare to transfer the billed amount to patient responsibility rather than your provider's responsibility.-You should report the GA modifier only when an ABN form was presented to the patient.

Heads up: Many non-Medicare payers also have intraoperative monitoring coverage policies that often have diagnosis-driven medical necessity limitations.

Company Web sites or provider representative phone contacts are often the best sources of information for payer-specific details.