Neurology & Pain Management Coding Alert

Find out how to capture technical reimbursement in a facility setting

Reporting intraoperative monitoring (IOM) can open up a coding can of worms--from non-covered baseline studies to abandoned modifiers. Review these FAQs to make sure you-re not committing some common errors in your 95920 coding.

Question 1: What is IOM and how do I report it?

Answer: Intraoperative monitoring is the ongoing electrophysiologic testing and monitoring that a neurologist performs to ensure a patient's stability and protection from nerve damage during surgery. You should report this service using time-based, add-on code 95920 (Intraoperative neurophysiology testing, per hour [List separately in addition to code for primary procedure]).
 
Because 95920 is an add-code, never report it as a stand alone code. When you perform IOM, you first need to complete a baseline study to establish a means of comparison. Report 95920 with the appropriate companion code for this baseline, such as 95860 (Needle electromyography; one extremity with or without related paraspinal areas). For more information: CPT includes a full list of allowable companion codes in its descriptor for 95920.

Important: You can perform and separately code multiple baseline studies, but -you only bill the IOM as one line unit,- cautions Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver. As a time-based code, the total units of 95920 that you report are based solely on monitoring time and not the number of studies performed.

Warning: Don't forget to subtract out from IOM the time involved in setting up, conducting and interpreting the baseline study(ies), says Hammer. Also, don't count your -standby time- as intraoperative monitoring, such as waiting in the operating room for the surgeon to arrive. Rule of thumb: Start your clock for IOM immediately after the surgery begins.

Timing is Everything

Question 2: If I perform IOM for less than one hour, should I append modifier 52 (Reduced services) to 95920?

Answer: According to the majority of coding experts and AANEM guidelines, modifier 52 is not required when reporting 95920. However, you should only bill for IOM if you provide monitoring for at least thirty-one minutes. Any amount of monitoring time less than that should not be reported at all.

Similarly, when reporting more than one unit of 95920, you need to make sure that you record more than 30 minutes of additional monitoring time, says Tiffany Schmidt, JD, policy director for the AANEM. Example: After subtracting out time for a baseline study, you are able to document IOM for two hours and thirty-five minutes. You can bill for three units of 95920 with the appropriate testing code. But if you recorded two hours and twenty minutes of IOM, you would need to limit your reporting to 95920 x 2.

Get it in writing: One of the most common errors physicians can make is not fully documenting their monitoring time, says Kathleen Kibat, CPC, coordinator for educational coding services at Clarkson College in Omaha, Neb. -The key to getting paid is to document- your start and stop times, recommends Kibat.

Read the Fine Print for Remote Monitoring

Question 3: Does the monitoring physician need to be in the testing room the entire time to report IOM?

Answer: A physician can monitor from another location via video cameras or laptop, but you need to pay strict attention to carrier requirements for remote monitoring when reporting 95920. For example, Medicare allows for -online real-time monitoring,- explains Hammer. This means that a certified technician must be in the operating room; the neurologist must have an -online real-time- connection with that technician; and he needs to have immediate access to the surgeon so he can communicate any changes in the patient's status.

But even local Medicare carriers can differ in their local coverage determinations (LCDs) for remote monitoring with 95920. For instance, many -Medicare carriers request that there be one-on-one attention paid to the case being monitored,- reports Schmidt. Wisconsin Physician Services (WPS), however, allows the neurologist to monitor more than one patient at a time, provided that she is solely dedicated to performing this service. In other words, she also can't be seeing patients in the office while performing IOM.

Pitfall: Even if your carriers allows for expanded supervision options for 95920, -you-ve also got to meet the supervision criteria for any baseline studies that are being performed,- cautions Hammer.

Bottom line: When it comes to requirements for remote IOM, you should check with individual carriers and their corresponding LCDs for documenting and reporting 95920. Remember: You will also want to ask the insurer how to record the place of service when monitoring remotely.

Negotiate for Technical Reimbursement

Question 4: Do I need to append modifier 26 when performing IOM in a facility setting? What about if I own the equipment and employ the technician?

Answer: In many cases, you will still need to append modifier 26 (Professional component) to 95920, but the definitive answer is going to depend on how your payer reimburses the facility. If your payer, like Medicare, uses a grouper-based payment system, it will already include reimbursement for any technical components to the hospital, explains Hammer. In such cases, you still must append modifier 26 to any testing procedure, such as IOM, EMGs, or nerve conduction studies.

But you don't need to give up any hope for technical reimbursement in these cases. -A physician would have a claim on at least part of the technical component of services performed in the hospital if he owns the equipment, employs the technician, or personally performs the test,- says Schmidt. If you can meet any of these criteria, establish a clear arrangement with the facility up front, so that you can bill them directly for technical services.

Tip: Get answers to these important questions from the very beginning of a reimbursement arrangement with any facility:

- Where do I send the bill? Don't just assume it goes to accounts payable.

- What type of form does the facility want for the bill? Some departments may prefer a more familiar invoice over a HCFA form.

- What is the scale for reimbursement? Determine if your payment will be straight across Medicare-s allowable reimbursement for a procedure-s technical component or an appropriate percentage above that.