ExchangeCoverageHigh impact
Intraoperative Neurophysiologic Monitoring (IONM) Update: Effective 6/15/26
Ambetter·IA · Neurosurgery, Orthopedics, General Surgery +2 more·Claims & Billing
Effective date
Jun 15, 2026
We identified it
Aug 26, 2026
Summary
Effective June 15, 2026, Ambetter Health is implementing new billing and payment requirements for Intraoperative Neurophysiologic Monitoring (IONM) services on Marketplace plans. Only CMS-recognized payable code 95940 with modifier G0453 is covered; code 95941 is non-covered. All claims must meet strict criteria including exclusive patient attention, maximum 4 units per 60 minutes, appropriate place of service codes, and cannot be billed by surgeon or anesthesia provider.
Action Required
By June 15, 2026: Billing team must immediately update billing software to enforce IONM coverage rules for Ambetter Marketplace plans. (1) Configure system to ONLY accept code 95940 with modifier G0453 as payable; deny all claims for code 95941. (2) Add validation rules requiring: exclusive undivided attention to one patient, maximum 4 units per 60-minute period, total units do not exceed monitoring time available, place of service is 19, 21, 22, or 24, and service is NOT billed by surgeon or anesthesia provider. (3) Update claim denial logic to reject any IONM claims that violate these criteria. (4) Brief all providers and surgical staff that IONM services cannot be billed as part of global surgical package. (5) Review any pending IONM claims submitted under old guidelines and reprocess if necessary. Failure to implement these rules will result in automatic claim denials for non-compliant IONM submissions.