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Local Coverage Determination (LCD)

Intraoperative Neurophysiological Testing

L34623

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34623
Original ICD-9 LCD ID
Not Applicable
LCD Title
Intraoperative Neurophysiological Testing
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 02/01/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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Issue

Issue Description

Biannual review completed with no change in coverage.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Intraoperative neurophysiological testing may be used to identify/prevent complications during surgery on the nervous system, its blood supply, or adjacent tissue.

Monitoring can identify new neurologic impairment, identify, or separate nervous system structures (e.g., around or in a tumor), and can demonstrate which tracts or nerves are still functional. Intraoperative neurophysiological testing may provide relative reassurance to the surgeon that no identifiable complication has been detected up to a certain point, allowing the surgeon to proceed further and provide a more thorough or careful surgical intervention than would have been provided in the absence of monitoring.

Some high-risk patients may be candidates for a surgical procedure only if monitoring is available. To establish medical necessity the following guidelines must be followed:

    Intraoperative testing may be indicated with the following types of surgery:
  1. Surgery of the aortic arch, its branch vessels, or thoracic aorta, including internal carotid artery surgery, when there is risk of cerebral ischemia
  2. Resection of epileptogenic brain tissue or tumor
  3. Resection of brain tissue close to the primary motor cortex and requiring brain mapping
  4. Protection of cranial nerves:
    1. tumors that are optic, trigeminal, facial, auditory nerves
    2. cavernous sinus tumors
    3. oval or round window graft
    4. endolymphatic shunt for Ménière's disease
    5. vestibular section for vertigo
    6. microvascular decompression of cranial nerves
  5. Correction of scoliosis or deformity of spinal cord involving traction on the cord
  6. Protection of spinal cord where work is performed in close proximity to cord as in the removal of old hardware or where there have been numerous interventions
  7. Spinal instrumentation requiring pedicle screws or distraction
  8. Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication where function of spinal cord or spinal nerves is at risk
  9. Resection of:
    1. Spinal cord tumors
    2. Neuromas of peripheral nerves or brachial plexus, when there is risk to major sensory or motor nerves
  10. Surgery for:
    1. intracranial AV malformations
    2. arteriovenous malformation of spinal cord
    3. surgery for intractable movement disorders
    4. cerebral vascular aneurysms
  11. Arteriography, during which there is a test occlusion of the carotid artery
  12. Circulatory arrest with hypothermia
  13. Distal aortic procedures, where there is risk of ischemia to spinal cord
  14. Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks
  15. Basil ganglia movement disorders
  16. Surgery as a result of traumatic injury to spinal cord/brain
  17. Deep brain stimulation

Limitations
For reimbursement, 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

The benefits of intraoperative neurophysiologic testing are attainable under optimal recording and interpreting conditions.

Due to the nature of these services and the potential for significant morbidity in some procedures requiring intraoperative monitoring, Medicare expects to see these services used in the hospital setting only. As the level of anesthesia may significantly impact the ability to interpret intraoperative studies, continuous communication between the anesthesiologist and the monitoring physician is expected when medically indicated.

It is also expected that a specifically trained technician, preferably registered with one of the credentialing organizations, will be in continuous attendance in the operating room, recording and monitoring a single surgical case, with either the physical or electronic capacity for real-time communication with the supervising neurologist or other physician trained in neurophysiology.

Intraoperative monitoring is not medically necessary in situations where historical data and current practices reveal no potential for damage to neural integrity during surgery. Monitoring under these circumstances will exceed the patient's medical need.

Due to the potential risk for morbidity with many of the above noted 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. Monitoring may be performed from a remote site, as long as a trained technician (see detail above) will be in continuous attendance in the operating room, with either the physical or electronic capacity for real-time communication with the supervising physician (MD/DO). Technical criteria (mandatory) include that at least 8 recording channels be available (16 if EEG is monitored) for all intraoperative neurophysiological monitoring. The remotely supervising physician must have the ability to watch the tracings as they are obtained in real-time in the operating room, as well as the baseline electrophysiological test and the monitoring tracings from earlier in the case.

Technical criteria (mandatory) for remote monitoring also include (a) routine real-time auditory or written communication between the supervising physician and the operating room and (b) the capability for telephone communications as needed between the supervising physician and the monitoring technologist, operating surgeon, and the anesthesiologist.

The equipment must also provide for all of the monitoring modalities that may be applied - auditory-evoked response, electroencephalography/electrocorticography, electromyography and nerve conduction, and somatosensory-evoked response.

Undivided attention to a unique patient may be required during some surgeries, such as during response to acute events or identification of the cerebral cortex to be resected or spared from resection. The monitoring physician must have a plan in place to transfer care to another physician of any other case during those times. When paying undivided attention to a unique patient, the physician must code and bill only for that one case during those times. For other medically necessary intraoperative neurophysiologic monitoring, a physician may monitor up to three cases simultaneously.

Medicare does not provide for reimbursement of "incident to" care in the hospital setting. More than one patient may be monitored at once; however, claims for physician services must be submitted only for the time devoted to monitoring when attention is directed exclusively to one patient.
Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

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Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
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Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
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MAC Meeting Information URLs
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Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
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Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

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Revenue Codes

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

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 Group 1 Codes:

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

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 Group 1 Codes:

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Additional ICD-10 Information

General Information

Associated Information
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Sources of Information
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Bibliography

Bose B, Sestokas AK, Schwartz DM. Neurophysiological detection of iatrogenic C-5 nerve deficit during anterior cervical spinal surgery. J Neurosurg Spine. 2007; 6:381-385.

Liem L, Benbadis S. Intraoperative neurophysiological monitoring. Retrieved 12/09/2015 from: http://emedicine.medscape.com/article/1137763-overview. 2010.

Nuwer MR, Emerson RG, Galloway G, et al. Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Clinical Neurophysiology Society. Neurology. 2012;(78):585-589.

Principles of Coding for Intraoperative Neurophysiologic Monitoring (IOM) and Testing.
American Academy of Neurology. February 2012

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
02/01/2024 R15

02/01/2024: Biannual review completed with no change in coverage.
  • Other ((Review))
07/28/2022 R14

Posted 07/28/2022: Removed “surgery for intractable movement disorders” under # 10 e, as it was listed twice under Coverage Indications. Minor typographical errors corrected throughout the LCD. Moved references listed under Sources of Information to Bibliography and made corrections to reflect proper AMA formatting. Review completed 06/30/2022 with no change in coverage.
  • Other ((Review))
07/30/2020 R13

07/30/2020 Documentation Requirements and Utilization Guidelines removed due to redundancy since located in A57604 - Billing and Coding: Intraoperative Neurophysiological Testing. Review completed 07/07/2020 with no change in coverage.
  • Other (Review)
11/01/2019 R12

Change Request 10901 Local Coverage Determinations (LCDs): it will no longer be appropriate to include Current Procedure Terminology (CPT)/Health Care Procedure Coding System (HCPCS) codes or International Classification of Diseases Tenth Revision-Clinical Modification (ICD-10-CM) codes in the LCDs. All CPT/HCPCS, ICD-10 codes, and Billing and Coding Guidelines have been removed from this LCD and placed in the Billing and Coding Article related to this LCD. Consistent with Change Request 10901, if any language from IOMs and/or regulations was present in the LCD, it has been removed and the applicable manual/regulation has been referenced.
  • Revisions Due To Code Removal
01/01/2019 R11

01/01/2019 Annual review completed 12/04/2018 with no changes in coverage.
  • Other (Annual)
10/01/2018 R10

10/01/2018 ICD-10 Code Updates: deleted code I63.8 and added I63.81 and I63.89, in Group One. Description change to codes I63.333, I63.343, and M50.01 in Group One.
  • Revisions Due To ICD-10-CM Code Changes
01/01/2018 R9

 

01/01/2018 Annual review completed 12/05/2017 with no changes in coverage.
  • Other (Annual)
10/01/2017 R8

10/01/2017 ICD-10 code updates, description changes for Group 1 codes I63.211,I63.212, I63.22, I63.323, I63.333, I63.513, I63.523, and I63.533. Typographical error corrected.At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

 

 
  • Revisions Due To ICD-10-CM Code Changes
  • Typographical Error
10/01/2016 R7 02/01/2017 Annual review done 01/03/2017 no change in coverage.
  • Other
10/01/2016 R6 10/01/2016 ICD-10-CM code updates Added to group 1 G56.13, G56.23, G56.33, G57.03, I60.2, I63.012, I63.013, I63.033, I63.113, I63.133, I63.213, I63.233, I63.313, I63.323, I63.333, I63.343, I63.413, I63.423, I63.433, I63.443, I63.513, I63.523, I63.533, I63.543 M50.020, M50.021, M50.022, M50.023 Deleted from Group 1 I60.20, I60.21,M50.02 Group 1 revised description I77.79. Deleted from group 2 S06.0X6A.
  • Revisions Due To ICD-10-CM Code Changes
02/01/2016 R5 02/01/2016 Annual review no change in coverage removed CAC information and updated references.
  • Other (annual review)
10/01/2015 R4 10/06/2015 - Due to CMS guidance, we have removed the Jurisdiction 8 Notice and corresponding table from the CMS National Coverage Policy section. No other changes to policy or coverage.
  • Other
10/01/2015 R3 02/01/2015 Annual review and updated references and format.
  • Other (Maintenance, annual review)
10/01/2015 R2 08/01/2014 Code description change codes M50.01, M84.58.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R1 07/01/2014 Code updates 2014 removed codes M47.17, M47.18 and M51.07.
  • Revisions Due To ICD-10-CM Code Changes
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Public Versions
Updated On Effective Dates Status
01/23/2024 02/01/2024 - N/A Currently in Effect You are here
07/20/2022 07/28/2022 - 01/31/2024 Superseded View
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