Download: 2020 ProPep® Coding Guide
|CPT Code||Descriptor 1||2020 Relative Value Unit (RVU)2||2020 Medicare National Average Facility2||Hospital Inpatient Payment|
|+95940||Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code of primary procedure)||.94||$34||Included in DRG payment|
|+95941||Continuous intraoperative neurophysiology monitoring from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code of primary procedure)||N/A||N/A||Included in DRG payment|
|+G0453||Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes. (List separately in addition to code of primary procedure)||.94||$34||Included in DRG payment|
|95907-26||1-2 nerve conduction study||1.54||$56||Included in DRG payment|
|51785-263||Needle electromyography studies (EMG) of anal or urethral sphincter, any technique||2.66||$96||Included in DRG payment|
1 Current Procedural Terminology (CPT) ® is copyright 2019 American Medical Association.
2 Final Physician Fee CMS-1715-F. Medicare physician fee schedules are facility site of service and national averages without geographically adjustment.
3 CCI edits may prevent separate payment when CPT code 51785 is billed with 95940, G0453 or 95907.
|ICD-10 diagnosis codes if patient has urinary retention or frequency prior to surgery|
|R33.9 - Retention of urine, unspecified|
|R39.14 - Feeling of incomplete bladder emptying|
|R32.0 - Unspecified urinary incontinence|
|R35.0 - Frequency of micturition|
|R39.15 - Urgency of urination|
Q: What primary nerve codes would typically be billed for EUS nerve identification during prostatectomy surgery?
A: For (EUS) Urethral Sphincter nerve identification during prostate surgery, typical CPT codes billed would be 51785 (anal/urethral sphincter EMG).
Q: Is there a HCPCS code for the ProPep® disposable monitoring supply?
A: HCPCS code A4649 (surgical supply, miscellaneous) should be used for individual consideration or patient pay option. Tracking of surgical supplies also allows allocation of costs for future rate setting purposes. There is no specific HCPCS code for the ProPep® monitoring supply and is typically not paid separately.
Q: How do I describe the nerve identification process during prostatectomy?
A1: If nerve identification was performed prior to and/or after the pedicle dissection – Nerve identification was performed during this surgery by placing recording electrodes in the levator muscles in the pelvic floor. The perineal branches of the pudendal nerve were stimulated and the locations of these nerves were identified from the apex of the prostate to the base. Corresponding compound motor action potentials were elicited and documented and allowed for real-time evaluation of these nerves.
A2: If nerve identification was performed prior to and/or after Apical dissection - the recording electrodes were placed directly into the External Urethral Sphincter and stimulation around the periphery of the urethral sphincter allowed for identification of the branch(es) of the nerve innervating the external Urethral Sphincter.
Q: What add-on monitoring codes would typically be used during prostatectomy surgery?
A: CPT codes 95940, 95941 or G0453 are add-on codes and must be billed with the primary nerve conduction code.
Q: Can CPT code 51785 be billed for EMG of urethral sphincter performed during prostatectomy?
A: Verify directly with payer, but no coding edit (CCI edit) precludes billing 51785 with prostatectomy. However, coding edits may prevent separate payment when CPT code 51785 is billed with 95940, G0453 or 95907.
Q: Do payers cover use of ProPep® Nerve Monitoring during prostatectomy surgery?
A: Coverage decisions for IOM during prostatectomy surgery may vary so providers should verify directly with payers.
Q: Who can bill for intra-operative nerve monitoring (IOM)?
A: Surgeon experience to date indicates some commercial payers allow separate payment for IOM to operating surgeons. However, criteria for commercial payers may vary, so surgeons should contact their provider-relations representative.
Under Medicare rules, the operating surgeon is not paid separately for IOM. The following providers can bill if they have a separate provider number from the operating surgeon:
- A physician who is not performing the surgical procedure
- An audiologist trained and certified in electrophysiologic monitoring
- A physical therapist trained and certified in electrophysiologic monitoring
- A neurophysiologist, neurologist or physiatrist
Hospital Inpatient Payment
Medicare reimburses hospital inpatient services under the DRG payment system, which is an all-inclusive payment. Hospitals assign ICD-10 procedure and diagnosis codes for inpatient stays. Typical DRG assignment for prostatectomy surgery would be DRG 707 or DRG 708. 2020 Medicare national payment rate for DRG 707 is $11,704, and DRG 708 is $9,089. CPT code 55866 for prostatectomy was removed from the inpatient-only list effective January 1, 2018. If performed as outpatient, Medicare national average payment for CPT code 55866 is $8,413 under APC 5362.