ExchangeCoverageHigh impact
Intraoperative Neurophysiologic Monitoring (IONM) Update: Effective 8/1/26
Ambetter·DE · Neurosurgery, Orthopedics, Cardiothoracic Surgery +1 more·Claims & Billing
Effective date
Aug 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter Health of Delaware is implementing new billing and coverage criteria for Intraoperative Neurophysiologic Monitoring (IONM) services effective August 1, 2026. Only CPT code 95940 with modifier G0453 is covered; CPT 95941 is non-covered. All IONM claims must meet strict requirements including exclusive patient attention, maximum 4 units per 60 minutes, appropriate place of service codes, and must not be billed by surgeon or anesthesia provider.
Action Required
By August 1, 2026: Billing team must update billing system to (1) Only accept and process CPT 95940 with modifier G0453 for Ambetter Delaware Marketplace plans; (2) Deny or reject CPT 95941 claims automatically with explanation; (3) Implement system validation rules to enforce maximum 4 units per 60-minute period and prevent total units from exceeding monitoring time available; (4) Add required place of service validation (codes 19, 21, 22, or 24 only); (5) Add billing restriction to prevent claims from surgeon or anesthesia provider; (6) Update coding guidance and provider documentation to clarify that IONM services require exclusive, undivided attention to one patient. Providers must be notified of coverage changes and coding requirements. Failure to comply will result in claim denials for non-compliant submissions.