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CMS Code Alert

Thursday, December 06, 2012   (0 Comments)
Posted by: ASNM
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To: ASNM Members:


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 MedicarBeneficiaries to High Quality 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.

         *  G0453 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) would result in significant devaluation of the service.


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 mus be received by the agenc 5:00pm

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


2 Send comments to this e-mail address:

www.Regulations.gov


3. Submit a comment to CMS to express you 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. www.Regulations.gov


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.