CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Intraoperative neurophysiological monitoring (IONM) payment policy

Governs reimbursement, coding, documentation, and billing rules for intraoperative neurophysiological monitoring (IONM) for Neighborhood Health Plan of Rhode Island across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIntraoperative neurophysiological monitoring (IONM) payment policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionProviders must verify eligibility, coverage and authorization criteria prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

per 15 min95940 timing/unit

undivided attentionG0453 constraint

Medicaid, INTEGRITY, CommercialLines of business

Modifier 26 requiredModifier rule

Support active monitoring timeDocumentation

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Coverage and Billing Criteria

Coverage and billing criteria for IONM

Coverage is provided when services are medically necessary and meet coding, provider, and documentation requirements. Neighborhood may reference NCDs, LCDs, InterQual, Rhode Island EOHHS, and Clinical Medical Policies to determine medical necessity.

All services must be medically necessary. Neighborhood may reference NCDs, LCDs, InterQual, Rhode Island EOHHS, and Clinical Medical Policies to determine medical necessity.

The operating surgeon must order the IONM. Monitoring must be performed by a licensed physician who is a qualified neurologist and who is not the operating surgeon, the technical/surgical assistant, or the anesthesiologist.

Service setting: Codes 95940 and G0453 should be performed in hospital or ambulatory surgical center settings (place of service 19, 21, 22, or 24), even if the monitoring physician is remote.

Time and unit reporting for CPT 95940: reported per 15 minutes. Only time the monitoring professional was physically present in the operating room providing one-on-one patient monitoring counts; time in the OR is cumulative; monitoring may begin prior to incision.

Remote monitoring rule for G0453: billed only for undivided attention to a single patient (no simultaneous attention to multiple patients); monitoring professional may sum non-continuous time directed at one patient; real-time remote device required (no cell phones).

Modifier and related coding requirement: append modifier 26 to listed study/testing codes when filed with IONM as specified by coding guidance.

Documentation requirement: the medical record must support the services billed, medical necessity, and the time spent actively monitoring and correlate to the surgery; Neighborhood may request records and will deny claims lacking required documentation. If chat logs are used they must include ongoing times and reflect dedicated time for the beneficiary.

Billing and claims: claims are subject to contractual timely filing, AMA CPT/ICD-10/HCPCS coding standards, member eligibility, benefit coverage, and provider contracts. Payments are subject to these conditions and applicable plan cost sharing.

CPT, HCPCS, Modifiers and Time Units

Covered CPT Codes (selected list)CPTCovered

92652	Auditory evoked potentials; threshold estimation at multiple frequencies, with interpretation and report
92653	Auditory evoked potentials; neurodiagnostic, with interpretation and report
95822	Electroencephalogram (EEG); recording in coma or sleep only
95824	Electroencephalogram (EEG); cerebral death evaluation only
95829	Electrocorticogram at surgery (separate procedure)
95830	Insertion of sphenoidal electrodes for EEG recording
95836	Electrocorticogram from implanted brain neurostimulator pulse generator/transmitter, including recording, with interpretation and written report, up to 30 days
95851	Range of motion measurements and report; each extremity (excluding hand) or each trunk section
95852	Range of motion measurements and report; hand, with or without comparison
95857	Cholinesterase inhibitor challenge test for myasthenia gravis

1–10 of 37

1/4

95940 time unitCPT 95940 is reported per 15 minutes; time is cumulative while physically present one-on-one in the operating room (monitoring may begin prior to incision).

G0453 billing ruleG0453 must be billed only for undivided attention to a single patient; time directed to one patient may be aggregated across non-continuous intervals and real-time remote device presence is required (no cell phones).

Prior Authorization and Provider Responsibilities

Prior Authorization

Preauthorization and eligibility verification

It is the provider’s responsibility to verify member eligibility, coverage, and any required prior authorization before performing IONM services; refer to the plan-specific Prior Authorization Reference page and Neighborhood’s Clinical Medical Policies, or contact Provider Services at 1-800-963-1001 for questions.

Verify member eligibility and benefit coverage prior to rendering services.
Confirm whether prior authorization is required via the plan-specific Prior Authorization Reference page.
Consult Neighborhood’s Clinical Medical Policies for medical necessity criteria.
Contact Provider Services (1-800-963-1001) with questions about authorization or coverage.

Key Definitions

Intraoperative neurophysiological monitoring (IONM)

DefinitionIntraoperative neurophysiological monitoring (IONM) describes a group of procedures used during surgery to monitor neural pathways during high-risk neurosurgical, orthopedic, peripheral nerve, and vascular surgeries to help prevent damage and preserve nervous system function.

PurposeIONM assists surgeons by identifying new neurologic impairment, separating nervous system structures, and demonstrating functional tracts or nerves to help prevent intraoperative injury.

Scope of useUsed during procedures that place the nervous system or its blood supply at risk to provide information that may allow safer or more thorough surgical intervention.

Qualified monitoring professional

Ordering providerIONM must be ordered by the operating surgeon.

Qualified monitoring professional