Otolaryngology Coding Alert

With the right documentation and modifiers, some practices can earn big bucks.

If you think it has been difficult to get paid for interoperative nerve monitoring (IONM) when performing procedures such as a thyroidectomies or partotidectomies, then prepare yourself. CPT^® 2013’s code changes have made that just about impossible.

Re-Acquaint Yourself With This IONM Background

Through 2012, Medicare did not pay when the surgeon performed the interoperative nerve monitoring. Similar to anesthesia administration, Medicare feels the surgeon cannot pay adequate attention to the nerve monitoring beyond listening to a beep to support a separate payment.  Therefore, Medicare considered IONM bundled with any surgery.

However, if another person performed the monitoring, which includes watching a wave form and doing more than listening to beeps, Medicare would pay for the separate individual performing the monitoring.

Some private payers, however, did pay for the IONM performed by the surgeon through 2012.  However, that was a payer by payer reimbursement policy issue.

Review How IONM Changed in 2013

All that changed with CPT^® 2013 as of January 1, 2013. As the Otolaryngology Coding Alert previously reported, Medicare deleted +95920 (Intraoperative neurophysiology testing, per hour [list separately in addition to code for primary procedure]) and replaced it with two codes:

• 95940 — Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure)
• 95941 — Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure).

Descriptor Is Key to Why You Need a Separate Provider

These new codes have major new descriptions to the codes, which clarifies that these codes do not apply to the operating surgeon. Code 95940 states that the monitoring is performed “one on one … requiring personal attendance.”  This means the operating surgeon who is giving his or her personal attendance to the patient’s surgery cannot give their one on one personal attendance to the interoperative monitoring as well. In other words, the operating surgeon cannot fulfill the requirements for 95940 at the same time as he or she is meeting the requirements for the surgery. Therefore, the operating surgeon may not code and bill 95940. An entirely separate person must be performing the interoperative monitoring to report this code.

If the monitoring is within an audiologists’ scope of license in your state, the practice may consider using an audiologist in the OR for the interoperative monitoring services.   If the audiologist can perform this service based on their scope of license, the service would be billed out under the audiologist’s National Provider Identifier (NPI) and not the surgeon’s NPI. The same applies for other mid-level providers — for example, nurse practitioners (NP) or physician assistants (PA). If the interoperative monitoring is within a NP’s or PA’s state scope of license, they may perform the dedicated, one-on-one monitoring. Then you could bill the service out under their individual NPI.  Watch out: You may run into problems with non-Medicare payers who do not credential audiologists, NPs, or PAs. If this is the case, you should contact the payer to find out how they wish to have this dedicated, one-on-one monitoring billed. Get your answers in writing, and keep them as part of your compliance plan.

Code 95941 is for monitoring multiple cases at once outside the operating room. This is performed remotely, sometimes not even on the facility campus and at times, not even in the state or the country (the service is outsourced). Because 95941 is not performed in the operating room, the surgeon cannot use 95941 since they are in the operating room.  So, like 95940, 95941 requires a separate person monitoring the wave forms with real time communication to the surgeon as the surgeon operates. 

So, in conclusion, the surgeon cannot ever use either of these codes while performing surgery.  Another doctor in the practice, a NP, a PA or perhaps an audiologist, assuming that the service is in their state scope of services may perform the monitoring.  The NPI of this individual separate from the surgeon would be used on the claim for the IONM.