Intra-operative Nerve Monitoring Coding Guide. March 1, 2011

Intra-operative Nerve Monitoring Coding Guide March 1, 2011 Please direct any questions to: Patty Telgener, RN Vice President, Reimbursement Services Emerson Consultants (303) 526-7604 (office) (303) 570-2159 (cell) pattyt@emersonconsultants.com KB 3/11

TO OUR PARTNERS IN HEALTH CARE This document provides general reimbursement information provided to assist in obtaining coverage and reimbursement for healthcare services. These coding suggestions do not replace seeking coding advice from the payer and/or your own coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for interpretation of the appropriate codes to use for specific procedures. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third party payers as to the correct form of billing or the amount that will be paid to providers of service. All products should be used according to their labeling. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. KB3/11 2

Overview Intra-operative testing and monitoring of nerves is performed during otolaryngology, neurosurgical, orthopedic, and other procedures in which nerves can be at risk. Cranial nerve monitoring, such as facial nerve monitoring, can be used with primary procedures that include posterior fossa surgery for tumor removal, excision of acoustic neuroma, parotidectomy, and middle ear surgery. Laryngeal nerve monitoring in this context is generally related to thyroidectomy, parathyroidectomy and anterior cervical spine procedures. Peripheral nerve monitoring can be used with primary procedures that may include neuroplasty of the hand or foot, neuroplasty of major peripheral nerves of the arm or leg, nerve decompression, and excision of neuromas of hand, foot and major peripheral nerves. Testing associated nerves intra-operatively during surgical procedures can help prevent damage to nerves and other structures and can alert the surgeon of impending complications. Intra-operative nerve monitoring can be used to properly distinguish nerves, such as those embedded in tumor or scar tissue, that can be difficult to locate. It can identify signs that a nerve is becoming damaged from stretching or ischemia by monitoring abnormal discharges. Intra-operative nerve monitoring can also help differentiate between viable and nonviable portions of nerves. Documentation The medical necessity for nerve monitoring for each individual patient should be documented. It is helpful to include this information in the operative report itself. The operative report should clearly document the specific use of nerve monitoring, including the clinical information provided by the monitoring and how it helped with the surgical dissection. As appropriate, the operative report should document that the nerve monitoring was performed throughout the surgical procedure. The start and end times for nerve monitoring should be explicitly documented. Diagnosis Coding The diagnosis codes assigned generally reflect the reason for the primary procedure, rather than the associated nerve monitoring. Some Medicare contractors and commercial payers may have medical policies defining the ICD-9-CM codes for the primary diagnoses for which they feel nerve monitoring is medically necessary. Nerve monitoring performed and billed with other diagnosis codes will be denied. Providers should review Medicare Local Coverage Decisions for nerve monitoring to see if the ICD-9-CM diagnosis codes being used are listed as covered. Providers should also contact commercial payers for their coverage policies. Physician Coding and Reimbursement The following codes for electromyography testing, together with code 95920, may be appropriate to report intra-operative nerve monitoring. Payment shown is the Medicare national average under the RBRVS physician prospective payment system and does not include geographical variations. Because the primary procedure typically takes place in a facility, eg. a hospital, the RVUs and physician payment for nerve monitoring are shown for the facility setting only. All of the nerve monitoring codes below are designated as diagnostic tests by CMS so they have both a professional component, ie. interpreting the results, and a technical component, ie. using equipment to perform the test. Modifier 26 is appended to the codes to indicate that facility equipment was used so the physician is being reimbursed for the professional service only. Please see Coverage Rules, Medicare, Monitoring by the Operating Physician section on page 7. Intra-operative Neurophysiology Testing The key element in coding intra-operative nerve monitoring is code 95920. This code describes ongoing electrophysiology testing and monitoring performed during surgical procedures. KB3/11 3

Code 95920 is an add-on code and can never be reported by itself. It must always be used together with another code for the specific type of baseline nerve testing, such as EMG testing. + 95920-26 hour 3.14 $107 Instructions in the CPT manual specifically define the additional codes with which 95920 can be reported. These include EMG codes 95860, 95861, 95867, 95868, and 95870, as described below. Technically, code 95920 may not be reported with other EMG codes. Notes: Code 95920 is defined ʻper hourʼ. Time spent interpreting accompanying baseline EMG tests does not count toward the time for 95920; only the additional time spent for nerve monitoring is counted. Monitoring must last at least 31 minutes for code 95920 to be reported. Code 95920 is not reported when monitoring lasts less than 30 minutes. For longer monitoring, portions of an hour are counted only when nerve monitoring lasts over 30 minutes. For example, 3 hours 15 minutes of intra-operative nerve monitoring is reported as three units of 95920, and 3 hours 45 minutes of nerve monitoring is reported as four units of 95920. Code 95920 is used just once per hour even if multiple studies are performed. Cranial Nerve Monitoring e.g. Facial and Laryngeal Nerve Cranial nerve monitoring uses codes 95867 or 95868 for EMG of cranial nerve supplied muscles plus 95920 for intra-operative neurophysiology testing. Note that laryngeal nerve monitoring uses the same codes as all other cranial nerve monitoring because the recurrent laryngeal nerve is a branch of the vagus nerve, the 10 th cranial nerve. For nerve monitoring, these baseline EMG codes are reported together with code 95920. Cranial Nerve Monitoring e.g. Facial and Laryngeal Nerves, Unilateral Procedure 95867-26 Needle electromyography, cranial nerve supplied muscle(s), unilateral 1.20 $41 + 95920-26 hour 3.14 $107 Cranial Nerve Monitoring e.g. Facial and Laryngeal Nerves, Bilateral Procedure 95868-26 Needle electromyography, cranial nerve supplied muscle(s), bilateral 1.77 $60 + 95920-26 hour 3.14 $107 Notes: KB3/11 4

Code 95867 is used for EMG of one or more muscles supplied by a cranial nerve on one side of the body. Code 95868 is used for EMG of one or more muscles supplied by cranial nerves on both sides of the body. Code 95867 for unilateral and 95868 for bilateral cannot be reported together. Intra-operative Nerve Monitoring during Procedures on the Larynx Needle EMG of the larynx is performed to diagnose laryngeal nerve and muscle disorders, and for intraoperative monitoring during procedures performed on the larynx. Technically, this code cannot be paired with 95920. Instructions in the CPT manual list the specific EMG codes with which 95920 may be reported. Code 95865 is not included in this list. It should be noted that the list of associated codes for 95920 was last updated with CPT 2005 and code 95825 was new for CPT 2006. Notes: 95865-26 Needle electromyography, larynx 2.39 $81 Code 95865 is inherently bilateral. Intra-operative Nerve Monitoring with EMG Endotracheal Tube Code 95865 is commonly reported for laryngeal nerve monitoring via an EMG endotracheal tube. Technically, however, this code cannot be paired with 95920 unless a base code for another test can be paired with 95920. CPT 95867or 95868 plus 95920 are appropriate for laryngeal nerve monitoring via an EMG tube. Use of an EMG tube to monitor the vagus and recurrent laryngeal nerve does not alter the use of these codes. Peripheral Nerve Monitoring For nerve monitoring, each of these baseline EMG codes is reported together with code 95920. Nerve Monitoring for One Extremity 95860-26 Needle electromyography; one extremity with or without related paraspinal areas 1.46 $50 + 95920-26 hour 3.14 $107 Nerve Monitoring for Two Extremities KB3/11 5

95861-26 Needle electromyography; two extremities with or without related paraspinal areas 2.33 $79 + 95920-26 hour 3.14 $107 Other Peripheral Nerve Monitoring 95870-26 Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters 0.55 $19 + 95920-26 hour 3.14 $107 Notes: Codes 95860 and 95861 can be reported only once per patient. Codes 95860 and 95861 require evaluation of extremity muscles innervated by three nerves, with a minimum of five muscles studied per limb. 1 Code 95870 is reported for a limited study of one extremity (one arm or one leg) that does not meet the criteria for 95860 to 95864. Code 95870 is also used for study of a non-limb muscle, such as intercostal or abdominal wall, or for cervical or lumbar paraspinal muscles when the muscles of the corresponding limb are not also being tested. Other Peripheral EMG Technically, these codes cannot be paired with 95920. As noted, instructions in the CPT manual list the specific EMG codes with which 95920 may be reported. The codes below are not included on the list. 95863-26 Needle electromyography; three extremities with or without related paraspinal areas 2.80 $95 95864-26 Needle electromyography; four extremities with or without related paraspinal areas 2.99 $102 95872-26 Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied 4.20 $143 Notes: Codes 95863 and 95864 can be reported only once per patient. Codes 95863 and 95864 require evaluation of extremity muscles innervated by three nerves, with a minimum of five muscles studied per limb. 1 Both audio and visual readings are required to assign codes 95863, 95864 and 95872. 1Federal Register, October 31, 1997, p.59090 KB3/11 6

Additional Notes All of the EMG codes are designated as diagnostic tests by CMS. To be eligible for Medicare coverage, diagnostic tests are subject to specific requirements for physician supervision. The requirements do not apply when the tests are furnished to hospital inpatients. However, they do apply when the tests are furnished to hospital outpatients. CMS provides a code-by-code listing which indicates the exact level of physician supervision required for each diagnostic test. This list is incorporated into the Medicare Physician Fee Schedule Relative Value File and is updated quarterly. For January 2011, the EMG codes and 95920 are listed with value 09, defined as "concept does not apply", specifically when they are submitted with modifier -26. Coverage Rules Medicare Monitoring by the Operating Physician The operating surgeon should not report any of the nerve monitoring codes separately. Medicare does not pay separately for nerve monitoring when performed by the same surgeon who performed the primary procedure. Specifically, many Medicare coverage policies for CPT code 95920 states 2 : This test must be requested by the operating surgeon and the monitoring must be performed by a physician, other than: - the operating surgeon; - the technical/surgical assistant; or - the anesthesiologist rendering the anesthesia Specifically with regard to code 95920 for intraoperative neurophysiology testing, some Medicare policies also go on to state 3 : "Due to the potential risk for morbidity with many surgeries and the need for explicit and focused attention to both the monitoring and the procedure, Medicare does not expect to see operating surgeons submitting claims for this code." Beyond this, NCCI policy states 4 : Intraoperative neurophysiology testing (CPT code 95920) should not be reported by the physician performing an operative procedure since it is included in the global package. The physician performing an operative procedure should not bill other 90000 neurophysiology testing codes for intraoperative neurophysiology testing (e.g., 92585, 95822, 95860, 95861, 95867, 95868, 95870, 95900, 95904, 95925-95937) since they are also included in the global package. However, when performed by a different physician during the procedure, intraoperative neurophysiology testing is separately reportable by the second physician. Consultants have also advised that the EMG codes and 95920 were created and assigned RVUs on the basis of being performed by a physician other than the operating surgeon. Therefore, our best understanding of this issue is that the operating surgeon should not report the EMG codes and 95920. Additional information on this topic is available by contacting the local Medicare contractor, the AMA, and the AAO-HNSF. Monitoring by another Physician As noted, the National Correct Coding Policy on intra-operative neurophysiology testing code 95920 states that when performed by a different physician during the procedure, intraoperative neurophysiology testing is separately reportable by the second physician. 2 Example, Highmark Medicare Services, Local Coverage Determination L27469, Intraoperative Neurophysiologic Testing, revision date 9/9/2010 3 Example, Cigna Government Services, Local Coverage Determination L24058, Intraoperative Neurophysiologic Testing, review date 2/3/2010 4 Source: National Correct Coding Policy Manual, version 16.3, Chapter 8, section C, no.22; see also Chapter 11, section L, no.5. KB3/11 7

Therefore, a second physician such as a neurologist or neurophysiologist who performs these services during a procedure may report codes 95865, 95867, 95868 and 95920, for them and be reimbursed for them. Special rules apply when the second physician is in a group practice with the operating surgeon. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. However, physicians in the same group practice who are in different specialties may bill and be paid separately. 5 Therefore, a second physician in the same group but a different specialty from the operating surgeon may bill separately for intra-operative monitoring, but a second physician in the same group and same specialty may not. Physician Billing for Monitoring by Others Physicians may not bill for services performed by others in a facility, even if they are supervised by the physician. This means that a physician cannot bill for monitoring performed by an OR technician, nurse, physical therapist or any other professional employed by the hospital, regardless of the degree of physician supervision. Moreover, a physician cannot bill for monitoring performed by others in a facility even if they are employees of the physician, such as a Physician Assistant or Advanced Registered Nurse Practitioner. The services of these professionals may not be billed under the physicianʼs ID number. This is because there is no incident to billing in the facility setting for any service. 6 If the physician employs the professional who performs the monitoring or if the physician provides the equipment used, the physician may however be able to look to the hospital for additional reimbursement under a separate arrangement. Separate Billing by Non-Physicians An independent Physician Assistant, neurophysiologist, audiologist 7, nurse practitioner or other electrophysiology-certified provider working within the scope of his or her license who personally performs nerve monitoring can bill under his or her own Medicare provider number. 8 Remote Monitoring Typically, the monitoring physician is present in the operating room where the procedure is being performed. However, this is not always required. Some Medicare contractors allow remote monitoring, for example by digital transmission or video, as long as certain conditions are met. 9 Generally, the physician performing the service remotely must be monitoring in real-time and must be solely dedicated to performing this service. The physician monitoring remotely must also have the capacity for continuous or immediate contact with the operating surgeon. Alternately, a trained technician must be in continuous attendance in the operating room with the capacity for real-time communication with the remotely monitoring physician. Some contractors allow simultaneous monitoring of more than one patient. However, only the time devoted to each individual patient is counted. The time may be cumulative though it need not be continuous. Physicians should contact Medicare contractors and commercial payers for specific guidance on remote monitoring policies and requirements. Commercial Payers 5 Medicare Claims Processing Manual, Chapter 12, section 30.6.5. 6 Medicare Benefit Policy Manual, Chapter 15, section 60.1.B 7 American Academy of Audiology, Scope of Practice http://www.audiology.org/resources/documentlibrary/pages/scopeofpractice.aspx 8 Medicare Benefit Policy Manual, Chapter 15, section 60.2 and section 80; see also sections 190, 200, and 210 9 Examples: Trailblazer Health Enterprises, Local Coverage Determination L26800, Intraoperative Neurophysiologic Monitoring, revision date 10/18/2010; Cigna Government Services, Local Coverage Determination L24058, Intraoperative Neurophysiologic Testing, review date 2/3/2010; WPSIC, Local Coverage Determination L10944, Intraoperative Neurophysiologic Testing, revision date 12/1/2010 KB3/11 8

Many commercial payers follow Medicare policies, guidelines and edits. However, some commercial payers may have different interpretations and practices. Physicians should contact local payers to verify coverage, appropriate coding, and payment. KB3/11 9

Facility Coding and Reimbursement Facility, coding and reimbursement depend on the setting, e.g. In-patient or outpatient, and the type of facility such as hospital or Ambulatory Surgery Center. Also note that facilities do not append TC to the CPT codes. It is understood that the facility is billing for the technical component. Hospital Outpatient Hospitals use CPT codes to report outpatient services. Payment shown is the Medicare national average under the APC hospital outpatient prospective payment system and does not include geographical variations. The Status Indicator shows how each code is handled for payment purposes. Cranial and Peripheral Nerve Monitoring Used With 95920 CPT Description APC 95860 95861 95867 95868 95870 +95920 Notes: Needle electromyography; one extremity with or without related paraspinal areas Needle electromyography; two extremities with or without related paraspinal areas Needle electromyography, cranial nerve supplied muscle(s), unilateral Needle electromyography, cranial nerve supplied muscle(s), bilateral Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters APC Weight Status Indicator CY2011 Payment Level II Nerve and Level II Nerve and Level II Nerve and Level II Nerve and 0215 Level I Nerve and Muscle Tests 0.6518 S $45 hour N/A N/A N N/A Coding guidelines given for physicians apply to hospital outpatient services as well. NCCI edits bundle EMG codes 95867 and 95868 and nerve monitoring code 95920 with a variety of ENT primary procedures, including the parathyroidectomy and exploration procedures represented by 60500 and 60502. NCCI edits also bundle many of the other EMG codes and 95920 with a variety of peripheral nerve surgical procedures. Hospitals should review current NCCI edits when reporting these codes. The EMG codes are paid separately in addition to the payment for the primary surgical procedure. Status Indicator S indicates that payment is always made at 100% of the rate and is not reduced even when other separately payable services are also billed. The intra-operative nerve monitoring code 95920, however, is not paid separately. Status Indicator N indicates that payment for intra-operative nerve monitoring is ʻpackagedʼ and included with payment for the primary procedure, so no separate payment is made. Many commercial payers use Medicareʼs APC methodology or a similar type of fee schedule to reimburse hospitals for outpatient services. However, some payers may have different practices or policies. Hospitals should contact local payers regarding separate payment for code 95920. Other EMG (Not Used with 95920) CPT Description APC 95863 Needle electromyography; three extremities with or without related paraspinal areas APC Weight Status Indicator CY2011 Payment Level II Nerve and 1.1728 S $81 KB3/11 10

95864 Needle electromyography; four extremities with or without related paraspinal areas Muscle Tests Level II Nerve and Level II Nerve and 95865 Needle electromyography, larynx Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all Level II Nerve and 95872 sites of each muscle studied Hospital Inpatient Hospitals assign ICD-9-CM procedure codes for inpatient services. The ICD-9-CM codes then form the basis for the DRG system that Medicare uses to reimburse hospitals for inpatient stays. ICD-9-CM provides a specific code for intra-operative nerve monitoring: 00.94 intra-operative neurophysiologic monitoring For Medicare, a single DRG is assigned for the entire hospital stay and the associated payment is designed to encompass all services rendered during the stay. So hospital payment for nerve monitoring is included as part of the overall surgical DRG payment. Some commercial payers also use DRGs to reimburse hospital inpatient services, or they may use a per diem or per case method. Under all of these methodologies, separate payment is not made for intraoperative nerve monitoring. Ambulatory Surgery Center Medicareʼs list of ʻASC Covered Surgical Procedures for CY 2011ʼ includes only primary surgical procedures. The payment to the ASC for the primary surgical procedure includes the nerve monitoring services. Nerve monitoring services have not been designated as ʻintegral to covered surgical proceduresʼ in the ASC setting as other ancillary services have. They are not separately payable to the facility. Payment by commercial payers may vary depending on the ASCʼs contract and the patientʼs benefits. ASCs should contact local payers to verify coverage, coding, and payment. KB3/11 11

Frequently Asked Questions (Note: Please refer to complete NIM coding guide for more details and references.) 1. Who can bill for intra-operative nerve monitoring? Under Medicare rules, the following providers can bill if they have a separate provider number from the operating surgeon: - A physician who is not performing the surgical procedure. - An audiologist trained and certified in electrophysiologic monitoring. - A physical therapist trained and certified in electrophysiologic monitoring. - A neurophysiologist, neurologist or physiatrist. For other payers, physicians should contact their provider relations representative. 2. If the operating surgeonʼs partner performs the nerve monitoring, can this be billed separately? In general, the operating surgeonʼs partner cannot bill for nerve monitoring separately. From the payer perspective, a physician and the physicianʼs partners are the same person. Since the operating surgeon cannot bill nerve monitoring separately, a partner cannot either. One common exception is when the operating surgeon and the partner are in different specialties, in which case some payers allow them to bill separately. (Medicare Claims Processing Manual, Chapter 12, 30.65) 3. Can an anesthesiologist bill for EMG tube placement? No. Under Medicare rules, anesthesiologists cannot separately code or bill the use of a scope or laryngoscope in placing an endotracheal tube. This is considered integral to the anesthesia service. (Source: NCCI Policy Manual, version 16.3, Chapter 2, section B, no. 4) 4. Can the hospital outpatient surgery department bill for intra-operative nerve monitoring? Under Medicare APCs, the hospital can bill for the technical component of the EMG codes such as CPT 95867 or CPT 95868 and receive separate payment. However, Medicare considers the intraoperative nerve monitoring code 95920 a ʻpackagedʼ service. The hospital can and should submit the code but payment for 95920 is included in the payment for the primary procedure, so no separate payment is made for code 95920. Hospital should contact commercial payers for separate payment information for 95920. 5. Can an ASC bill for intra-operative nerve monitoring? For Medicare, the answer is no. The nerve monitoring services codes are not listed as approved codes for ASCs and are not separately payable to the facility. The payment to the ASC for the primary surgical procedure includes the nerve monitoring services. Payment by commercial payers may vary depending on the ASCʼs contract and the patientʼs benefits. ASCs should contact local payers to verify coverage, coding, and payment. 6. Can a company that provides intra-operative nerve monitoring get reimbursed for the monitoring in a hospital or ASC? A company that provides intra-operative nerve monitoring services that performs and bills for the nerve monitoring under its own Medicare provider number may be reimbursed. The payment ʻpackagingʼ and edit ʻbundlingʼ rules do not apply because the provider is billing completely independently of the physician or facility. 7. What monitoring codes are used during thyroid surgery? CPT code 95868 for bilateral cranial nerve monitoring is used because the EMG tube monitors the nerve bilaterally. However, if monitoring unilaterally CPT95867 can be used. The nerve being monitored is a branch of a cranial nerve. 8. When is code 95865 used? KB3/11 12

The AMA has published that needle EMG of the larynx is performed for intra-operative monitoring during procedures performed on the larynx. 9. Why isnʼt 95865 cross-referenced as one of the EMG codes with which code 95920 can be reported? The list of associated codes for 95920 was last updated with CPT 2005. Code 95865 was new in CPT 2006. We have alerted the AMA to the discrepancy. 10. How many units can be billed for code 95920? Code 95920 is defined as ʻper hourʼ. It is used just once per hour even if multiple EMGs are performed. For example, if a patient was monitored for three hours, the provider would bill 3 units for 95920. Portions of an hour are counted only when nerve monitoring lasts over 30 minutes. For example, 3 hours 15 minutes of intra-operative nerve monitoring is reported as 3 units of 95920, and 3 hours 45 minutes of intra-operative nerve monitoring is reported as 4 units of 95920. Note that monitoring must last at least 31 minutes for code 95920 to be reported. Code 95920 is not reported when monitoring lasts less than 30 minutes. 11. How many units can be billed for CPT 95867 or 95868? The cranial nerve monitoring codes 95867 and 95868 are defined as ʻcranial nerve supplied muscle(s)ʼ so only one code is used regardless of how many muscles are being tested. KB3/11 13