Blurring of local and remote practice models threatens IOM's future.

In this issue of Neurology®, Nuwer et al. present the results of a recent survey of American Academy of Neurology members concerning practice patterns for intraoperative neurophysiologic monitoring (IOM). The study confirms the continued growth of IOM but also sheds light on striking differences between 2 practice models—“local”monitoring and the “remote” telemetry. For historical reasons, a single Current Procedural Terminology (CPT) code has applied to both models, generating considerable ambiguity and resulting in lack of transparency, particularly to third-party payers, which now presents a serious challenge to the field and to neurologists providing IOM services. On November 1, 2012, with the issuance of the Centers for Medicare & Medicaid Services’s (CMS’s) Final Rule for Medicaid physician payments, this challenge became a crisis that threatens to limit IOM services available to Medicare patients. Traditionally, the practice of IOM has adhered to an on-site or “local” model. The physician neurophysiologist is present in the operating room (OR), or monitors from a nearby display. The physician readily and quickly enters the OR to confer with the technologist, anesthesiologist, and surgeon, and to review medical records and imaging studies. The physician directly supervises the technologist who operates the IOM equipment, and may assist in the identification and resolution of technical problems that interfere with effective IOM. Whether routinely or at times of crisis, the on-site neurophysiologist is able to contribute effectively to real-time decision-making through live, face-to-face interaction with the surgeon and the anesthesiologist. The intensity of local monitoring typically limits the physician to monitoring and supervising up to 3 cases concurrently. Indeed, the local model is very much analogous to an anesthesiologist supervising a similar number of residents or nurse anesthetists. Importantly, the utility of IOM has been established based on extensive Class I and Class II evidence acquired using the traditional, local, practice model. A different practice model, remote telemetry, has gained enormous popularity over the last decade. The remote IOM model developed as a natural outgrowth of traditional monitoring. First, direct cable connections, and then telephone modem–based systems, made it possible for the monitoring physician to maintain close tabs on a case from the office, and to monitor more than one case from a central location. Prior to 2001, the 95920 IOM CPT code required that IOM be performed under direct supervision, and so the monitoring physician was necessarily present on-site. In 2001, the direct supervision requirement was eliminated, and monitoring from anywhere was permissible, as long as there was a real-time data link with the OR. Remote IOM is an important application of telemedicine in neurology; it complements traditional on-site monitoring, making IOM available to patients at remote locations and at sites without physicians with the necessary skills. Remote IOM is substantively different from the traditional on-site monitoring. Rather than being in the OR quickly when needed, the remote monitoring physician can never be physically present. Accordingly, the technologist functions without direct supervision; the neurologist has very limited ability to assist with the resolution of technical issues. Rather than face-to-face interaction, communication with OR personnel is restricted to text messages or telephone. Communication with the surgeon or anesthesiologist commonly entails “texting” with the technologist, who then relays messages. Depending on technological capabilities, the monitoring physician may or may not be able to access the medical record or imaging studies. This survey highlights strikingly different utilization patterns that further distinguish local and remote IOMmodels. While a relatively small minority of providers perform remote IOM, nearly half of the IOM cases in the United States are nowmonitored remotely. Although the 95920 IOM CPT code does not distinguish local from remote monitoring, it seems clear that the proliferation of remote monitoring following rescission of the direct supervision requirement likely accounts for much of the past decade’s exponential growth. The survey provides further insight by examining the types of cases monitored, and numbers of