ExchangeCoverageHigh impact
Intraoperative Neurophysiologic Monitoring (IONM) Update: Effective 9/1/26
Ambetter·NJ · Neurosurgery, General Surgery, Cardiothoracic Surgery +2 more·Claims & Billing
Effective date
Sep 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter from WellCare of New Jersey is implementing new billing and payment criteria for Intraoperative Neurophysiologic Monitoring (IONM) services effective September 1, 2026. Only CMS-recognized payable code 95940 with modifier G0453 will be covered; code 95941 is non-covered. Billing must comply with strict criteria including exclusive patient attention, maximum 4 units per 60 minutes, and appropriate place of service codes (19, 21, 22, or 24). IONM cannot be billed by surgeons or anesthesia providers as it is included in the global surgical package.
Action Required
By August 31, 2026: Billing team must update billing software and claims submission protocols to (1) accept only CPT code 95940 with modifier G0453 for IONM services on Ambetter Marketplace plans; (2) deny or reject claims for CPT code 95941 as non-covered; (3) implement system edits to enforce maximum 4 units per 60-minute period; (4) require validation that total units billed do not exceed total monitoring time available; (5) add claim-level edits to prevent IONM billing by surgeon or anesthesia provider; (6) enforce place of service requirements (codes 19, 21, 22, or 24 only). Update provider encounter forms and billing instructions to clarify that IONM is included in the global surgical package and should not be billed separately by surgical/anesthesia providers. Providers and billing staff must be educated on these changes. Claims submitted after September 1, 2026 that fail to meet these criteria will be denied.