Government Tracking - American Society of Neurophysiological Monitoring

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New Code UPDATE G0453

To: ASNM Providers:

This communication provides important summary comments regarding G0453, bullet

points to consider, recommendations to CMS, some pertinent literature references, and

guidance for submitting comments to CMS.

Code G0453: Summary Comments

Intraoperative Neurophysiological Monitoring (IONM) is the application of

electrophysiological and vascular monitoring procedures during surgery to identify

surgical targets, assess efficacy of surgical interventions, and allow early warning and

avoidance of injury to nervous system structures. During surgery, supervising IONM

professionals continuously monitor the patient’s neurophysiologic signals to detect

adverse changes which may require corrective action. IONM services are utilized by

health systems and hospitals across the country, including academic institutions, major

medical centers, community hospitals large and small and rural hospitals in

underserved areas. All provide services to Medicare beneficiaries.

As stated in earlier communications, AMA-CPT code 95920 will be retired at the end of

2012. AMA-CPT replacement codes 95940 for onsite in-room monitoring and 95941 for

remote or nearby monitoring of more than one case simultaneously were offered. CMS

did not find the 95941 code acceptable and on November 1, 2012 announced a final

rule placing CMS Code G0453 in its stead. The code requires that the supervising

professional devote exclusive attention to monitoring a single Medicare beneficiary at a

time. Comments on Code G0453 will be accepted until 5:00 PM, December 31, 2012.

G0453 will either severely restrict or completely deny IONM services to Medicare

beneficiaries and their surgeons who rely upon IONM for the prevention of life changing

intraoperative insults to the nervous system. Accordingly, unmodified implementation of

G0453 will confer upon patients, families, surgeons, hospitals and society the burden of

emotional and financial consequences of potentially avoidable surgical complications.

Unmodified implementation of G0453 will severely erode access to high quality IONM

by: 1) profoundly affecting training programs through inability to attract and place highly

qualified graduates, 2) resulting in abandonment of IONM by practitioners because of

an unsustainable compensation model, 3) resulting in possible discontinuation of IONM

by hospitals at all levels through an unsupportable economic burden and 4) requiring

surgeons or anesthesiologists with variable background in neurophysiology to assume

professional supervisory responsibilities (if technological capability is available by some

means).

Given the profound affect that G0453 will have on provision of IONM services beginning

on January 1, 2013 we are deeply concerned that CMS has not allowed sufficient time

to receive comment from beneficiaries (and surgeons who operate upon them,

providers, and hospitals), to consider the impact of G0453 in light of comments, and to

entertain creative solutions that will assure provision of high quality IONM services to patients.

Suggested Bullet Points for Comment: Access of Medicare Beneficiaries to HighQuality IONM

Potential Risks of G0453:

G0453 is not consistent with current provider models: G0453 does not
consider and is inconsistent with all current provider models. IONM providers
typically monitor more than one patient at a time; this is the accepted standard of
care. The provider’s expertise and clinical knowledge is used to determine how
many patients it is appropriate to monitor at one time based on a number of
factors, such as provider experience level, the type of surgical case, and the skill
level of the technologist in the operating room. In this sense, the IONM model
has parallels with the accepted practice of anesthesia.

Availability of IONM services will be reduced: A CMS requirement to devote
exclusive attention to one patient at a time will greatly reduce the availability of
IONM services. Requiring a one on one model would necessitate at least twice
the number of professionals as currently available. A single supervising
professional could not provide services to two Medicare beneficiaries should both
require urgent IONM justified surgery.

Surgeons will be deprived of desirable services: In many areas throughout

the country the demand for IONM services already exceeds the supply of
qualified professionals. Surgeons, many of whom had trained with and have
come to value IONM, are increasingly requesting important intraoperative
information that IONM provides. G0453 will markedly restrict or preclude
availability of this information.

The level of qualified professional supervision will be lowered: Lack of
professional oversight will mean that supervision of the monitoring technologist (if
available) and the interpretation of data will be left to individuals who do not
possess education, training, knowledge, experience and credentials in
intraoperative neurophysiology.

Hospitals may incur increased overhead costs: Hospitals will be faced with
the choice of paying for the service or abandoning IONM. Costs for hospitals
wishing to provide IONM services with professional oversight will rise through
inability to obtain reimbursement. Absent professional oversight risk of adverse
neurological surgical outcomes will rise.

Go453 does not correctly value the service: The value CMS assigned to
G0453 does not correctly value the service described in the code. The current
delivery model and accepted standard of care allows for concurrent monitoring of
more than one patient. Thus, billing the AMA-CPT code 95941 had a lower value
than 95940, based upon supervision from a remote/nearby location as opposed
to in room supervision exclusively devoted to one patient. Utilizing the 95941
model (allowing more than one patient)

Recommendations:

Delay implementation and/or consider modification of G9453: Given serious

service disruption, reduction of quality IONM care, and profound reduction in availability

of IONM that looms on the horizon, we strongly urge CMS to either delay

implementation of G0453 or consider its modification (even if temporary) so that all

Medicare Beneficiaries can access IONM care after January 1, 2013. Temporary

modifications must consider continued financial survival of IONM as a specialty. For the

long term, the IONM community enthusiastically and sincerely welcomes an opportunity

to work with CMS in addressing CMS concerns and assuring delivery of quality IONM to

Medicare beneficiaries and their surgeons. Both need and rely upon the service.

Some Relevant References

• An extensive multicenter study demonstrated that a particular type of

intraoperative monitoring known as sensory evoked potentials reduced the risk of

paraplegia by 60% in spinal surgeries (Nuwer et al., 1995)

• A leading health center conducted an internal assessment and concluded that

spinal IOM is capable of substantially reducing injury in surgeries that pose a risk

to spinal cord integrity. They recommended that intraoperative monitoring be

used for all cases of spinal surgery for which there is a risk of spinal cord injury

(Erickson et al., 2005)

• A recent review of spinal monitoring by leading medical societies established

IOM as effective to predict when a patient has an increased risk of paraparesis,

paraplegia, and quadriplegia during spinal surgery (Nuwer et al., 2012).

• Early cost-effectiveness analyses indicate a clear benefit for IONM during spine

surgery (Sala, 2007; Ney, 2012).

Time Sensitive Call to Action

1- All comments must be received by the agency 5:00pm EST on December
31, 2012. (preferably within 7-10 days).

2- Send comments to this e-mail address:

http://www.regulations.gov/#!submitComment;D=CMS_FRDOC_0001-1076

3- Submit a comment to CMS to express your concern

4- Make sure you refer to file code CMS-1590-FC in your comments.

The current CPT code for intraoperative neurophysiology monitoring (IONM), CPT

95920, will be retired by CPT at the end of 2012.

In the final rule containing changes to the Physician Fee Schedule for 2013, CMS

invalidated the proposed new CPT code 95941 for IONM and replaced it with HCPCS

code G0453. The change is effective January 1, 2013. (See link to the 2013 Medicare

Physician Fee Schedule - relevant portion is at bottom of page 69068 and on page

69069).

Please submit a comment to CMS to express your concern about this action and the

impact it will have on patient care and access to monitoring services. Encourage your

colleagues to do the same. We have strived to provide important information and

bullet/talking points in this communication. The most effective comments include

specifics about how your patients and practice will be impacted.

All comments must be received by the agency 5:00pm EST on December 31, 2012 and

will be public. For CMS to consider options before January 1st implementation, we

strongly urge comment within 7-10 days from receipt of this communication.

Because of the tight timeframe for this policy, the best way to make a comment is to do

it online. Please use the link below to submit the comments. Make sure you refer to file

code CMS-1590-FC in your comments.

Enter your contact information and paste (or upload) your comments at the address

below. There is a word limit for comments so if your comments are more than a few

paragraphs, you will need to attach them as a word document or PDF.

http://www.regulations.gov/#!submitComment;D=CMS_FRDOC_0001-1076

ASNM will remain steadfast in representation of its members, its commitment to survival

of IONM as a specialty, to provision of high quality IONM services to all patients and

their surgeons, and to the growth and sustenance of IONM as a valued service. We are

pursuing all possible means of communicating with CMS before the implementation of

G0453.

Please act now.

The purpose of this communication is to assure the ASNM membership that their professional Society is acutely aware of member concerns over the new G0453 code. The Society recognizes the serious risk to patients and their surgeons who will have limited access to Intra-Operative Neurophysiological Monitoring. The Society strongly supports the value of IONM in patient care during high risk surgical procedures. Your Society is very actively involved in this issue and looks forward to participating with CMS toward provision of safe, reliable and meaningful IONM services for all patients.

Antoun Koht, MD, President

John Hastings, MD, President-elect

John McAuliffe, MD, upcoming President-elect

Gene K. Balzer, PhD, upcoming Board Member

Stanley Skinner, MD, previous Board Member

1- All comments must be received by the agency 5:00pm EST on December

31, 2012. (preferably within 7-10 days)

2- Send comments to this e-mail address: