The ASNM is involved in various advocacy initiatives related to the practice and profession of Intraoperative Neurophysiological Monitoring (IONM).

CPT Code G0453

This communication provides important summary comments regarding G0453, potential risks of G0453, recommendations to CMS, and pertinent literature references.

CPT 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. The Centers for Medicare and Medicaid Services (CMS) have previously stated that 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 subsequently offered. However, 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. 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 effect 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.

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, the 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)


Given the potential for serious service disruption and reduction of quality IONM care, the ASNM has strongly urged 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.

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 (Erikson 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 at., 2012)
  • Early cost-effectiveness analyses indicate a clear benefits for IONM during spine surgery (Sala, 2007; Ney, 2012).