22103
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.28
Facility
$115.90
Non-Facility
$115.90
Documentation Required
- See appendix for additional details on documentation requirements (policy references an appendix)
- All medical necessity criteria must be clearly documented in the member's medical record and made available upon request.
- Billing rule: For continuous intraoperative neurophysiology monitoring in the operating room with one-on-one monitoring requiring personal attendance, increments of less than 8 minutes should not be billed.
- No documentation requirements are specified in this excerpt.
Key Coverage Criteria
- Intraoperative EMG monitoring of the facial nerve during surgery for cholesteatoma, including mastoidotomy or mastoidectomy
- ICD-10 codes covered if selection criteria are met for intraoperative SEPs (as listed): "H93.3x1 - H93.3x9" Disorders of acoustic nerve [compression].
- ICD-10 codes covered if selection criteria are met for intraoperative SEPs (as listed): "I06.0 - I06.9" Diseases of aortic valve.
- ICD-10 codes covered if selection criteria are met for intraoperative SEPs (as listed): "I35.0 - I35.9" Nonrheumatic aortic valve disorders.
- ICD-10 codes covered if selection criteria are met for intraoperative SEPs (as listed): "I70.0" Atherosclerosis of aorta.
- ICD-10 codes covered if selection criteria are met for intraoperative SEPs (as listed): "I71.00 - I71.9" Dissection of aorta.
1 Active Policy
AETNA-CPB-0697 — Intraoperative Neurophysiological Monitoring
Related Codes
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