Have you seen a decline in your Intraoperative Neuromonitoring insurance reimbursements lately? Are you seeing more and more payersdenying your claims stating procedure was not medically necessary or procedure was experimental. Ever thought why –
The answer to your question is changes in the medical policies and guidelines. Every Payer has their own clinical policies and they keep revising it from time to time. Recently AMA (American Medical Association) stated, beginning January 1st 2012, Codes for SSEPs Upper and Lower limbs and MEPs Upper and Lower Limbs are combined, so instead of CPT 95925 (somatosensory evoked potential;Upper Limbs) and CPT 95926 (somatosensory evoked potential ;Lower Limbs) CPT 95938 should be used if SSEPs are performed in both upper and lower limbs (Do not report 95938 in conjunction with 95925, 95926). Similarly CPT 95939 should be used for Motor Evoked Potential studies performed in both upper and lower limbs (Do not report 95939 in conjunction with 95928, 95929).
With these changes, some of the carriers have also changed or revised their clinical policies like Aetna where in they no longer are going to cover intraoperative SSEPs for certain procedures like implantation of spinal cord stimulator, hip replacement surgery, thyroid and parathyroid surgery etc. Aetna also considers intra-operative EMG monitoring during spinal surgery experimental and investigational due to insufficient evidence that this technique provides useful information to the surgeon in terms of assessing the adequacy of nerve root decompression, detecting nerve root irritation, or improving the reliability of placement of pedicle screws at the time of surgery.
On the other hand payers like Medicare does not pay for Intraoperative Neuromonitoring CPT code 95920 for conditions like Stenosis, Radiculopathy, Degenerative disk diseases, Disc displacement without Myelopathy and Spondylosis without Myelopathy.
Now the question is how do you combat with such denials? Here are some steps you should take into consideration:
- Review the clinical policies and verify that the denial is justified.
- Experimental and/or investigational procedures may be covered if you justify it with the letter of medical necessity. Submit all the accompanying medical notes and explain why the procedure was requested and performed. Any clinical journals or articles included will a huge plus.
- Also note that your POS (place of service) should be marked correctly on the claim. You wll be surprised that payers like Medicare will deny the claims as not medically necessary if your POS is incorrect. Most of the claims that involve hospital stays lasting less than 1 day will trigger the denial. Medicare considers IONM services to be medically necessary only in an inpatient setting.
Also be very diligent when billing Workers Comp Carriers with these new CPT codes. Review the State specific fee schedule to make sure that these new CPT codes are included in the State Workers Comp fee schedule. Chances are that state may not have revised their fee schedule and if you bill your claims with new CPT codes your claims are going to get denied. For example: State of CA does not recognize CPT 95938 and CPT 95939. If in doubt, call the payer for their clinical guidelines or check on their website to have the latest information.
Another important point to note with recent changes in SSEPs and MEPs CPT codes are that 95938 and 95939 are not listed as primary procedures for CPT 95920. Not sure if this is just an oversight by AMA and if they are going to have an ERRATA but this means that if you are billing just the SSEPs Upper and Lower limbs along with CPT 95920, be prepared to write appeal letters if your claim gets denied because CPT 95920 is an add on code and not a stand alone code.
Be sure your practice is up to the speed with these revisions to ensure proper insurance reimbursements and reduced claims denials.