ExchangeCoverageHigh impact
Intraoperative Neurophysiologic Monitoring (IONM) Update: Effective 8/1/26
Ambetter·NC · Neurosurgery, Cardiothoracic Surgery, Orthopedics +2 more·Claims & Billing
Effective date
Aug 1, 2026
We identified it
Aug 26, 2026
Summary
Effective August 1, 2026, Ambetter of North Carolina is updating IONM (Intraoperative Neurophysiologic Monitoring) reimbursement requirements for Marketplace plans. Only CMS-recognized payable codes (95940, G0453) will be covered; CPT 95941 is no longer covered. Billing must comply with strict CMS 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 July 31, 2026: Billing team must update billing system to ONLY accept CPT 95940 and HCPCS G0453 for IONM services on Ambetter Marketplace plans; block or reject CPT 95941 claims. Configure system edits to enforce: (1) maximum 4 units per 60-minute period, (2) total units cannot exceed monitoring time available, (3) Place of Service must be 19, 21, 22, or 24, and (4) claims from surgeon or anesthesia provider are automatically denied. Update provider billing guidelines and encounter documentation to clarify that IONM must be billed by the monitoring technician only, not surgical or anesthesia teams. Train billing staff on new requirements. Failure to comply will result in claim denials and potential overpayment recovery.