Otolaryngology Coding Alert

Question: The otolaryngologist resects a facial neuroma. Nerve monitoring is performed during the surgery to avoid facial nerve damage. How should we bill for this service?

Minnesota Subscriber

Answer: Facial nerves may be monitored intraoperatively to enhance the preservation of facial nerves during some extensive surgery, such as acoustic neuroma resection and cochlear implantation.
 
CPT 95920 (intraoperative neurophysiology testing, per hour [list separately in addition to code for primary procedure]) may be used to report facial nerve monitoring. CPT also tells physicians, however, that this add-on code should be billed only when monitoring is performed with the following studies:
 

92585 auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive

95822 electroencephalogram (EEG); sleep only

95860 needle electromyography, one extremity with or without related paraspinal areas
 

95861 ... two extremities with or without related paraspinal areas

95867 ... cranial nerve supplied muscles, unilateral

95868 ... cranial nerve supplied muscles, bilateral

95900 nerve conduction, amplitude and latency/ velocity study, each nerve; motor, without F-wave study

95904 ... sensory

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

95926 ... in lower limbs
 

95927 ... in the trunk or head

95930 visual evoked potential (VEP) testing central nervous system, checkerboard or flash

95933 orbicularis oculi (blink) reflex, by electrodiagnostic testing

95934 H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle

95936 ... record muscle other than gastrocnemius/soleus muscle

95937 neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method.

All of these codes describe the "setup" of a study; 95920 is added to report time spent monitoring the patient.
 
Although otolaryngologists are unlikely to perform most of these studies, one exception is 95927. This study involves stimulating a given nerve and monitoring the progress of the signal from the source to the brain. If the waves that the monitor generates become distorted, the otolaryngologist knows the nerve is at risk and is able to discontinue before damage is caused.
 
If the facial nerve monitoring is performed for diagnostic purposes, the primary procedure would be reported along with 95927 for the setup of the monitoring and 95920 to report monitoring time (with the appropriate number of units, representing each hour of monitoring, noted in the units box).
 
Note: Neurophysiologic studies are usually performed in a facility, so modifier -26 (professional component) should be appended. Since the physician provides supervision and interpretation services when billing a service with modifier -26, the physician must provide a separate written report.
 
Most carriers, however, pay for these tests only when they are performed diagnostically, regardless of the codes that are reported.
 
If the monitoring is done to guide the otolaryngologist, the carriers consider it included in the primary procedure, e.g., the acoustic neuroma resection.
 
Many of the carriers that cover intraoperative facial nerve monitoring will pay separately only if a physician other than the surgeon who performed the primary procedure does the monitoring. In other words, the carrier may pay if the anesthesiologist monitored the facial nerve while the otolaryngologist performed surgery or may consider payment part of the primary service if the otolaryngologist also does the monitoring.
 
Otolaryngologists may also use 92516 (facial nerve function studies [e.g., electroneuronography]) to report facial nerve monitoring. Although this study involves monitoring the facial nerve, it is primarily used as a tool to diagnose Bell's palsy and other facial paralysis disorders and should not be reported for monitoring used for guidance purposes.