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January, 2012

Clinical Neurophysiology News Newsletter of the American Clinical Neurophysiology Society Message from the President Is Clinical Neurophysiology About to Die?

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For some of us, the future of clinical neurophysiology looks very bleak. Dark clouds seem to be assembling on every horizon. After all, isn't it the same technology except with a few more bells and whistles that we knew from 50 years ago? Aren't reimbursements likely to drop and won't there be increasing regulations and restrictions on clinical practice? Aren't there fewer young people going into the field and doesn't our group appear to be aging as a whole? What is fundamentally new and exciting? Maybe it is time to pack it in. A Shakespeare sonnet laments that "on the ashes of his Douglas R. Nordli Jr., M.D youth doth lie‌ consumed by that with which he was nourished by." Is that us and clinical neurophysiology? I don't think so. In fact, rather than a field headed for senescence, there is a general excitement and energy about the field that is palpable and the scientific advances have never been more promising. Let's look at the evidence.

2012 Annual Meeting and Courses February 7-12, 2012 Marriott Rivercenter San Antonio, TX Program Co-Chairs: Cecil Hahn, M.D. & Francis Walker, M.D. Course Chair: William O. Tatum IV, D.O. Visit www.ACNS.org to register and make your hotel reservation. Newsletter Editor Jonathan C. Edwards, M.D

This year's scientific program, crafted by Cecil Hahn and Francis Walker, is better than ever. Many aspects of central and peripheral clinical neurophysiology have representation with very stimulating topics. The speakers are stellar and there will be ample opportunity for lively exchanges. The courses, assembled by Bill Tatum, are largely composed of an "all-professor" faculty of talented speakers whose passion for their work is evident in every aspect of their presentations. Through years of meticulous, diligent work they are poised to pass along all sorts of clinical pearls to those eager to learn. There were a record number of abstracts submitted for the program - more than double any previous year! Our membership is more diverse and we're seeing a fresh infusion of young talent. Exciting collaborative projects have been developed, great new special interest groups have formed, and new professional connections made. We continue to be a society of friendly, cordial, and very approachable individuals. Where else could you walk up to the authors of all of the most prestigious books in the field and start a casual conversation at the drop of a hat? Have you noticed the nature of the submissions to the journal? In my view they are getting better and better. I'm finding more articles that immediately pique my interest, have genuine value and will contribute to clinical care. Thanks to the stewardship of John Ebersole it is on an even better financial footing and its scientific impact continues to rise. What about clinical practice? In my area, digital technology has transformed a test that some regarded as destined for the trash heap to a vital test that provides timely and (Continued on page 2)


American Clinical Neurophysiology Society 2011-2012 Council Members PRESIDENT Douglas R. Nordli, Jr., M.D. Children's Epilepsy Center Chicago, IL 1ST VICE PRESIDENT Susan T. Herman, M.D. Beth Israel Deaconess Medical Center Boston, MA 2ND VICE PRESIDENT Frank W. Drislane, M.D. Beth Israel Deaconess Medical Center Newton, MA SECRETARY Aatif M. Husain, M.D. Duke University Medical Center Durham, NC TREASURER Stephan Schuele, M.D., M.Ph. Northwestern University Neurology Chicago, IL

IMMEDIATE PAST PRESIDENT Peter W. Kaplan, MB, FRCP Johns Hopkins Medical Center Baltimore, MD PAST PRESIDENT Gareth J. Parry, M.D. University Minneapolis Neurology Minneapolis, MN COUNCIL MEMBERS Jonathan C. Edwards, M.D. Medical University of South Carolina Charleston, SC Terrence D. Lagerlund, M.D. Mayo Clinic Rochester, MN Suzette LaRoche, M.D. Emory University Medical Center Atlanta, GA Jamie R. Lopez, M.D. Stanford University Neurology Stanford, CA

Message from the President (continued) highly relevant information at a great value for the dollar. Yes, we've seen welcome improvements in imaging, and each iteration of MR technology brings something of additional value to patient care, but none of these compare with the quantum gain in value of the video EEG to the field of pediatric epilepsy. I can't tell you how many antiquated assumptions and preconceived notions about epilepsy in children have been shattered by careful review of video EEG data. In my center, like many throughout the world, we review the most interesting video EEG findings from the previous week in an hour long conference. It is the greatest source of continuing education I've ever had. The ability to actually capture the events in question, analyze them with polygraphic recordings, and correlate all of this with a variety of digital tools has proven to be immensely rewarding, both for patient care and also for professional enlightenment. I see similar changes in the ICU continuous monitoring and intraoperative monitoring. We have an opportunity to build on the solid foundation of our predecessors with a new technology that allows us to sift through massive amounts of data in record times so that we can cut quickly to the most relevant portions and help our patients. So, there are lots of reasons to be optimistic and excited, but what about the practice challenges, the regulations, and the poor reimbursement? Oh, the endless scuffles with administrators, which seem to number in the legions. Each time you eliminate some obstacle to care doesn't it seem like two others rear their ugly heads, like a grotesque Hydra? I've only been at this for about 22 years, but during that whole time it seems like this has been a constant droning noise, always there in the background. It doesn’t seem to change or go away, so I’m starting to ignore it. Thank goodness we have strong allies, like Marc Nuwer who keep beating Hydra back into submission so that we can continue the practice we enjoy, help our patients, and improve our discipline. I won't lie. Things looked a little bleak some years ago, but fortunately, new vitality and energy has come to our field and our society. There are many reasons to set aside our concerns and to be optimistic for a bright future. Now, in short, I still see the ash heap, but arising from it is the phoenix!

Doug President, American Clinical Neurophysiology Society

Suraj Ashok Muley, M.D. St. Joseph's Hospital and Medical Center Phoenix, AZ Piotr W. Olejniczak, M.D. Louisiana State University Health Sciences Center New Orleans, LA William O. Tatum IV, D.O. Mayo College of Medicine Jacksonville, FL Francis O. Walker, M.D. Department of Neurology Winston-Salem, NC Elizabeth J. Waterhouse, M.D. Medical College of Virginia Medical Center Richmond, VA

Journal of Clinical Neurophysiology Dr. John Ebersole, Journal Editor, welcomes suggestions and guest editors for special issues of the Journal. Potential authors may now submit their manuscript online at www.EditorialManager.com/JCNP.


ACNS Newsletter

2011 Neurophysiologic Intraoperative Monitoring and ICU EEG Monitoring Courses

After the huge success of last November's Neurophysiologic Intraoperative Monitoring Course in Baltimore, the American Clinical Neurophysiology Society (ACNS) decided to hold mid-year courses again this year. In September, 2011, comprehensive two-day courses on Intraoperative Monitoring and ICU EEG Monitoring were held at the Sheraton Atlanta in Atlanta, Georgia.

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Attendees ranged from neurophysiology trainees to experienced neurologists and neurophysiologists as well as many electroneurodiagnostic technologists. The NIOM Course had 61 attendees and the ICU EEG Monitoring Course had 54 attendees. Speakers included experts in the field of neurophysiology from many of the top IOM and EEG monitoring institutions in the country. Participants attending the Atlanta courses came from all over the United States, Canada, the United Kingdom and Saudi Arabia. Several vendors were also on hand displaying their equipment and some presenting lectures. The ACNS graciously thanks the following sponsors and vendors for their support: Cadwell, CareFusion, Compumedics, Medtronic, Natus Medical, Nihon Kohden, Persyst and UCB Inc. The Saturday evening reception was very well-attended and allowed participants to socialize among themselves and with the vendors. In case you weren't able to attend the mid-year courses, don't miss the ACNS Annual Meeting and Courses which will take place February 7 through February 12, 2012, at the Marriott Rivercenter in San Antonio where both IOM and EEG monitoring courses will be held in addition to other courses on EMG, Sleep, EMG and EEG Technology and Applied Autonomic Neurophysiology as well as a Nerve Conduction Workshop and EP Reading Session.

AMERICAN CLINICAL NEUROPHYSIOLOGY SOCIETY 2012 ANNUAL MEETING AND COURSES FEBRUARY 7-12, 2012 MARRIOTT RIVERCENTER* - SAN ANTONIO, TEXAS *Please note that some early Courses will be held at the Marriott Riverwalk, located across the street from the Marriott Rivercenter.

Click on the picture at right to view the preliminary program. You can also visit the ACNS Website (www.ACNS.org) to view or download the Preliminary Program, register for the Annual Meeting and/or Courses and to make your hotel reservation.


ACNS Newsletter

THIRD ANNUAL ACNS NEUROPHYS BOWL

Co-Chairs, Drs. Lawrence J. Hirsch, M.D., and Mark A. Ross, M.D., invite you to participate in the Third Annual ACNS NEUROPHYS BOWL which will take place on Friday, February 10, 2012, from 5:30 p.m. to 6:45 p.m., at the Marriott Rivercenter in San Antonio, Texas. Come cheer on your colleagues as they test their knowledge of clinical neurophysiology!

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To participate as an individual or with a team, download the form from www.ACNS.org and email to ACNS@ssmgt.com or fax to 860-286-0787.

ACNS PROFESSIONAL DEVELOPMENT MENTORING PROGRAM Friday, February 10, 2012 6:45 p.m. This year’s Annual Meeting will include a new professional development session for clinical neurophysiologists. The program is targeted to neurology residents, clinical neurophysiology fellows, and junior faculty at the instructor or assistant professor level. Attendees will be matched with a clinical or research mentor in clinical neurophysiology for a brief one-on-one mentoring event at the beginning of the ACNS Attendees Reception on Friday. The goals of the program are to foster career development in clinical neurophysiology, encourage active participation in the many activities of ACNS, and facilitate networking. Please sign up on the Annual Meeting and Courses registration form to be matched with a mentor, or to volunteer to serve as a mentor, or contact Marie Westlake, Associate Executive Director, by email at ACNS@ssmgt.com or phone at 860-243-3977.

ATTENTION FELLOWSHIP DIRECTORS!

The Consortium of Clinical Neurophysiology Program Directors (CCNPD) will meet Saturday, February 11 at 12:30 p.m. to 1:30 p.m. at the Marriott Rivercenter in Conference Rooms 13/14. Please plan to attend.


ACNS Newsletter

Invitation to Exhibitors and Sponsors Opportunities for exhibitors and sponsors are available for the 2012 Annual Meeting and Courses of the American Clinical Neurophysiology (ACNS), to be held February 7 - February 12, 2012, at the Marriott Rivercenter in San Antonio, Texas. Show dates are February 10 and February 11, 2012. Sponsorships of non-CME functions, such as meals and receptions, are available. The third annual Neurophys Bowl will take place on Friday, February 10, beginning at 5:30 p.m., immediately preceding the attendees' reception.

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As always, all food functions and poster sessions will be held in the Exhibit Hall. A detailed exhibit brochure can be found at the link below, along with the meeting schedule. For questions, please contact Marie Westlake, Associate Executive Director, at ACNS@ssmgt.com or 860-2433977.

Click the HERE to Access the Full Exhibitor Brochure!

AMERICAN CLINICAL NEUROPHYSIOLOGY SOCIETY 2013 Annual Meeting and Courses February 5 - February 10, 2013 Miami Marriott Biscayne Bay Miami, Florida Scientific Program Co-Chairs Jonathan C. Edwards, M.D., and Mark Hallett, M.D.

Call for Proposals for Symposia, Clinical Workshops, and Other Didactic and Interactive Sessions SUBMIT ONLINE: www.ACNS.org SUBMISSION DEADLINE IS MONDAY, JANUARY 30, 2012

Proposals are being sought for Symposia, Clinical Workshops and other didactic and interactive sessions for the 2013 American Clinical Neurophysiology Society (ACNS) Annual Meeting which will take place at the Miami Marriott Biscayne Bay in Miami, Florida. This call for proposals is to enhance the opportunities for clinicians and investigators to introduce advanced scientific or clinical topics for those interested in the field of clinical neurophysiology. Proposals should include a title, outline of the session, list of moderator and speakers, and an overview of the objectives, scientific content, target audience and educational needs. Format for proposals of various types is listed below.

(Continued on page 6)


ACNS Newsletter

AMERICAN CLINICAL NEUROPHYSIOLOGY SOCIETY 2013 Annual Meeting and Courses Professional Practice Gaps Programs of the ACNS are designed to address the following professional practice gaps and submissions will be evaluated with reference to these gaps:

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Gap #1. Emerging Areas of Practice. Neurological intraoperative monitoring (NIOM) and intensive care unit EEG monitoring (ICU EEG) are new and rapidly evolving areas of clinical neurophysiology. Few practicing neurologists have adequate training in these techniques, and physicians with competence in these areas are in great demand. Educational activities should cover both basic methodologies for those practitioners new to ICU EEG and NIOM, and innovative techniques. Gap #2. General Practice of Clinical Neurophysiology. Clinical neurophysiology procedures are performed by a large proportion of practicing US neurologists, many of whom have little or no formal training in clinical neurophysiology. Many clinical neurophysiology procedures (e.g. evoked potentials, invasive EEG) are performed at low volume at most centers, and a forum for review and hands-on interpretation are essential to maintain competence in these areas. Several specific topics with significant gaps between current practice and ideal practice have been identified via review of the literature, review of clinical neurophysiology fellowship curricula, and surveys of ACNS members and Annual Meeting attendees.

These include: Peripheral neurophysiology: Pediatric EMG, critical illness related neurophysiology, and muscle ultrasound Basic EEG: Identification of normal variants, identification of artifacts, clinical correlation Pediatric EEG, especially neonatal EEG Digital EEG processing, e.g. quantitative EEG and trends for use in the intensive care unit, source localization, coregistration with neuroimaging, etc. Full band EEG, Ultrafast and ultraslow EEG NIOM: Motor evoked potentials, guidelines and standards of care for NIOM (e.g. indications, cost effectiveness) Evoked potentials: Current role of short-and long-latency EPs Video-EEG monitoring, especially invasive EEG Sleep: Use of new scoring system, implications for patient care Proposals do not need to be limited to the above topics. We especially welcome programs which have interactive or hands-on components, and are specifically designed to improve the procedural competence of attendees.

(Continued on page 7)


ACNS Newsletter Volume 4, Issue 1

2013 Annual Meeting and Courses (continued) Types of Presentations Symposia should be based on a scientific or clinical theme expanding cutting edge knowledge for a topic culminating into a conclusion or summary. Symposia should be planned for two hours and no more than four speakers. Sessions should utilize a lecture style learning format. Clinical Workshops are forums for clinical discussion and review of difficult clinical issues, within a 90minute time slot. These sessions may utilize case discussion, including video and neurophysiologic data, with a panel of "master" clinicians or utilize semiformal lecture type presentations reviewing clinical topics that would stimulate discussion. These sessions are most applicable to controversial topics or those in which there is less definitive data, and will not necessarily reach a conclusion. A question or series of questions should be introduced to the panel. If case review is selected, the chair is expected to ensure the cases are of high quality and appropriate data for discussion is available. Discussion Groups should be considered for topics that avail themselves to active participation of the audience. This format would encourage active audience participation and be directed toward difficult or controversial issues in clinical neurophysiology. The discussion group should be planned for a one hour time slot and contain no more than three discussants. The moderator of the program is expected to ensure topic discussion and prepare questions that will encourage active participation of the audience. Financial Disclosures It is the policy of the ACNS to ensure balance, independence, objectivity, and scientific rigor in all of its individually sponsored or jointly sponsored educational programs. In order to comply with the ACCME’s Updated Standards for Commercial Support, the ACNS and the Law requires that anyone who is in a position to control the content of an educational activity discloses all relevant financial relationships with any commercial interest pertaining to the content of the presentation. Should it be determined that a conflict of interest exists as a result of a financial relationship of a planner of the CME activity, the planner must recuse himself or herself from the planning for that activity or relevant portion of that activity. Should it be determined that a conflict of interest exists as a result of a financial relationship of a proposed presenter at a CME activity, the proposed presenter and the CME Committee must agree on a method to resolve the conflict. Refusal to disclose a conflict or the inability to resolve an identified conflict precludes participation in the CME activity. Submitters must sign a Financial Disclosure Form. Submissions are not considered complete and will not be submitted to the Program Committee unless this signature is on file. Content Validity Recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis. The Program Committee will review the proposals and may suggest changes to provide a balance in the overall program. REMINDER: Submission deadline is Monday, January 30, 2012


ACNS Newsletter

Consortium of Clinical Neurophysiology Program Directors Submitted by Piotr Olejniczak, M.D. The CCNPD sent out a survey to clinical neurophysiology program directors with questions about their experience with last RRC review and about their expectations from CCNPD. 1. Most survey responders (28/31 – 88.7%) were asked by RRC inspectors if the fellows pursued diplomate exams, but only 4 programs received a citation because of this deficiency.

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2. Most responders would prefer to communicate with other program directors through emails sent by the ACNS office (21/28 – 76%) and/or through an unmoderated listserv (13/28 – 46.4%). 3. Expectations for priority CCNPD services turned out to be very diverse. Suggested ideas included a bank of PIF proposals, citations and ACGME updates as well as creation of advocacy groups and political/ lobbying action committees. Some responders would prefer more formal meetings at different venues in contrast to the traditional lunches at the ACNS annual conferences. The byproduct of this inquiry was an update of the program directors census! Results of current clinical neurophysiology fellow census are still pending. Since the results of the survey turned out to be inconclusive for the most important services expected of CCNPD, we will be asking the program directors what topics re: CCNPD they would like to bring on the agenda of the upcoming meeting, which will take place on Saturday, February 11th at the ACNS meeting in San Antonio. I personally strongly support the idea of an “interactive” information bank.

Piotr Olejniczak, M.D., Chair, CCNPD

Case of the Month

Each issue of Clinical Neurophysiology News will feature a clinical case submitted by an ACNS member. The answer to the case will be available in the Members Only section of the ACNS website (www.acns.org). This issue’s case is submitted by William O. Tatum IV, D.O. For the answer, sign in to the Members Only section of the ACNS website: www.acns.org.

Case Study: A 23-year-old RH WM had drug-resistant epilepsy failing multiple AEDs. He developed normally without risk factors for epilepsy. Seizure onset began at 7 years of age manifest as “petit mal” seizures that occurred multiple times during the day. He was begun on ETH with improvement. When “grand mal” seizures occurred within the year he was changed to valproate yet continued to experience daily brief “petit mal” seizures. He was sent for evaluation of resective epilepsy surgery when “psychomotor seizures” became evident at puberty that were resistant to multiple AEDs previously failing trials of VPA, LTG, TPM, LEV, ZNS, and VNS. He was taking TRL 1200 mg PO BID and LTG 250 mg PO BID at evaluation. His neurological examination was normal. A high resolution brain MRI with an epilepsy protocol was normal. Interictal EEG demonstrated classic 3-Hz generalized spike-and-waves without focal features and normal background.


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Case of the Month (continued) What is the next step?

For the answer and outcome of this case, Please sign in to the Members Only section of the ACNS website: www.ACNS.org. If you do not know your username and/or password, please call the ACNS Executive Office at 860-243-3977 or email ACNS@ssmgt.com.

ACMEGS Course in San Antonio

The American Clinical MEG Society will be holding a full-day course on the Principles and Practice of Clinical Magnetoencephalography on February 8th, 2012 at the ACNS Annual meeting in San Antonio. The goal of the course is to enhance physicians’ and scientists’ competence and performance in the use of MEG techniques and interpretation of findings. ACNS designates this live activity for a maximum of 7 AMA PRA Category 1 Credits™. To learn more, click on the flyer below. The ACMEGS Annual Meeting will be held on Thursday, February 9th, also in San Antonio. For details, click HERE.


ACNS Newsletter

CPT Code Changes for 2012 Submitted by Marc R. Nuwer, M.D., Ph.D. ATTENTION: EMG CPT CODE CHANGES! There are major changes in the way that EMG services are to be coded for CPT in 2012. When NCV and EMG are performed together, new EMG codes must be used. The purpose is to remove some duplication in payment that occurred in the traditional coding system. Starting on January 1, three new codes exist for EMG when done on the same day as NCV testing: 95885 Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited

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95886 complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (Do not report 95885, 95886 in conjunction with 95860-95864, 95870, 95905) 95887 Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure) (Do not report 95887 in conjunction with 95867-95870, 95905) (Use 95885, 95886, 95887 in conjunction with 95900-95904) As a first example, the physician performs two motor NCV without F tests, two sensory NCV tests, one limb EMG testing six muscles, and another limb EMG testing three muscles. The new correct CPT coding will be: Motor NCV w/o F Sensory NCV EMG complete EMG limited

95900 95904 95886 95885

2 units 2 units 1 unit 1 unit

As a second example, the physician performed a two limb EMG without performing NCV on the same day. Both limbs included testing 6-7 muscles. Because no NCVs were performed that day on that patient, the old coding is used. The correct coding remains: EMG 2 limbs

95861

The EMG section has clarified that EMG equipment produces both audible and visual signals. It includes other details regarding the new EMG codes. The new header states: Needle electromyographic (EMG) procedures include the interpretation of electrical waveforms measured by equipment that produces both visible and audible components of electrical signals recorded from the muscle(s) studied by the needle electrode. Use 95870 or 95885 when four or fewer muscles are tested in an extremity. Use 95860-95864 or 95886 when five or more muscles are tested in an extremity. Use EMG codes (95860-95864 and 95867-95870) when no nerve conduction studies (95900-95904) are performed on that day. Use 95885, 95886 and 95887 for EMG services when nerve conduction studies (95900-95904) are performed in conjunction with EMG on the same day. Report either 95885 or 95886 once per extremity. Codes 95885 and 95886 can be reported together up to a combined total of four units of service per patient when all four extremities are tested. ATTENTION: SEP AND IOM CPT CODE CHANGES! Four limb testing of SEP and MEP. Beginning in January 2012, four-limb SEP and MEP tests will be coded as single codes each. Carriers no longer will accept code pairs 95925 plus 95926, or 95928 plus 95929. The new codes are: 95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs


ACNS Newsletter

CPT Code Changes for 2012 (continued) 95939 Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs Use these codes in place of the older pairs of codes when performing four-limb testing, beginning on January 1, 2012. Use these new codes as base codes for intraoperative monitoring when four limbs are monitored. ATTENTION: SLEEP TEST CPT CODE CHANGES! A series of Neurodiagnostic CPT code changes will take effect on January 1, 2012. These include New Definitions for the Sleep Section:

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The definitions are useful for certain current sleep test codes. Other words will be useful for future sleep test codes. The words appear in a header section in the codebook. They do not specifically change the numbering or descriptor of a particular code. The definitions are extensive. They are: Sleep medicine services include procedures that evaluate adult and pediatric patients for a variety of sleep disorders. Sleep medicine testing services are diagnostic procedures using in-laboratory and portable technology to assess physiologic data and therapy. All sleep services (95800-95811) include recording, interpretation and report. (Report with modifier 52 if less than 6 hours of recording for 95800, 95801 and 9580695811, and if less than four nap opportunities are recorded for 95805). Definitions For purposes of CPT reporting of sleep medicine testing services, the following definitions apply: Actigraphy: the use of a portable, non-invasive, device that continuously records gross motor movement over an extended period of time. The periods of activity and rest are indirect parameters for estimates of the periods of wakefulness and sleep of an individual. Attended: a technologist or qualified health care professional is physically present (ie, sufficient proximity such that the qualified health care professional can physically respond to emergencies, to other appropriate patient needs or to technical problems at the bedside) throughout the recording session. Electrooculogram (EOG): a recording of electrical activity indicative of eye movement. Maintenance of wakefulness test (MWT): a standardized objective test used to determine a person’s ability to stay awake. MWT requires sleep staging of the trials that are performed at defined intervals and is attended by a qualified health care professional. Multiple sleep latency test (MSLT): a standardized objective test of the tendency to fall asleep. MSLT requires sleep staging of the nap opportunities that are performed at defined intervals and is attended by a technologist or qualified health care professional. Peripheral arterial tonometry (PAT): a plethysmography technique that continuously measures pulsatile volume changes in a digit. This reflects the relative change of blood volume as an indirect measure of sympathetic nervous system activity which is used in respiratory analysis. Physiological measurements of sleep as used in 95805: the parameters measured are a frontal, central and occipital lead of EEG (3 leads), submental EMG lead and a left and right EOG. These parameters are used together for staging sleep. Polysomnography: a sleep test involving the continuous, simultaneous, recording of physiological parameters for a period of at least 6 hours that is performed in a sleep laboratory and attended by a technologist or qualified health care professional. The parameters measured are a frontal, central and occipital lead of EEG (3 leads), submental EMG lead and a left and right EOG, (from which sleep is staged), plus four or more additional parameters. The additional parameters typically required in polysomnography are listed below:


ACNS Newsletter

CPT Code Changes for 2012 (continued) A. Electrocardiogram (ECG) B. Nasal and/or oral airflow C. Respiratory effort D. Oxyhemoglobin saturation, SpO2 E. Bilateral anterior tibialis EMG

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Positive airway pressure (PAP): a device used to treat sleep-related breathing disorders with the use of noninvasive delivery of positive pressure to the airway. Examples include but are not limited to: CPAP (continuous positive airway pressure), bilevel PAP, AutoPAP (autotitrating or adjusting PAP), ASV (adaptive-servo ventilation). Remote: the site of service is distant from the monitoring center. Neither a technologist nor qualified health care professional is physically present at the testing site. Respiratory airflow (ventilation): the movement of air during inhaled and exhaled breaths. This is typically assessed using thermistor and nasal pressure sensors. Respiratory analysis: generation of derived parameters that describe components of respiration obtained by using direct or indirect parameters, e.g., by airflow or peripheral arterial tone. Respiratory effort: contraction of the diaphragmatic and/or intercostal muscles to cause (or attempt to cause) respiratory airflow. This is typically measured using transducers that estimate motion of the thorax and abdomen such as respiratory inductive plethysmography, transducers that estimate pressures generated by breathing muscles such as esophageal monometry, or by contraction of breathing muscles, such as diaphragmatic/intercostals EMG. Respiratory (thoracoabdominal) movement: movement of the chest and abdomen during respiratory effort. Sleep latency: the length of time it takes to transition from wakefulness to sleep. In the sleep laboratory it is the time from “lights out� to the first epoch scored as any stage of sleep. Sleep staging: the delineation of the distinct sleep levels through the simultaneous evaluation of physiologic measures including a frontal, central and occipital lead of EEG (3 leads), submental EMG lead and a left and right EOG. Sleep testing (or sleep study): the continuous, simultaneous monitoring of physiological parameters during sleep (eg, polysomnography, EEG). Total sleep time: a derived parameter obtained by sleep staging or may be estimated indirectly using actigraphy or other methods. Unattended: a technologist or qualified health care professional is not physically present with the patient during the recording session. ATTENTION: VNS and DBS CPT CODE CHANGES! Reprogramming implanted stimulators for DBS and VNS CPT codes have

American Clinical Neurophysiology Society Future Meetings

2012 Annual Meeting and Courses February 7 - February 12, 2012 Marriott Rivercenter San Antonio, Texas 2013 Annual Meeting and Courses February 5 - February 10, 2013 Miami Marriott Biscayne Bay Miami, Florida

2014 Annual Meeting and Courses February 4 - February 9, 2014 Westin Peachtree Plaza - Atlanta, Georgia


ACNS Newsletter

CPT Code Changes for 2012 (continued) minor changes effective January 2012. These codes are “per hour� codes. In cases where the service is half an hour or less, the short duration needs to be flagged in the coding system using modifier -52. In addition, the time taken for reprogramming should be documented in the medical records. The specific new CPT code rule change is given in the final sentence below: 95974 Complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour 95978 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour

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For 95974 and 95978, use modifier 52 if less than 31 minutes in duration.

Inservice Exam in Clinical Neurophysiology

PLEASE NOTE: REGISTRATION DEADLINE IS JANUARY 20 In February 2012, the American Clinical Neurophysiology Society (ACNS) will offer the 13th annual inservice examination assessing knowledge of clinical neurophysiology of the central nervous system. The examination is offered to Clinical Neurophysiology Fellows, Neurology Residents, and also to Attending Physicians. The examination will cover basic neurophysiology relevant for the understanding of clinical neurophysiology tests, technical aspects of physiological recording and testing methodology, and interpretation of tests with regard to neurological and general medical disease. Specific topic areas will include: Basic Neurophysiology Instrumentation Clinical EEG Epilepsy Clinical Evoked Potentials Sleep Monitoring Intraoperative Monitoring

In order to provide residents and program directors with the most useful feedback, scores will be given in each topic area as well as for the test as a whole. Program Directors will receive all scores and the residents will receive their individual scores. Percentile scores will be calculated separately for Neurology residents and Clinical Neurophysiology residents. Attending physicians taking the exam will receive their own scores.


ACNS Newsletter

Inservice Exam in Clinical Neurophysiology (continued) Clinical Neurophysiology training program directors, in particular, will find this examination to be a useful formal method of trainee assessment. Trainees will sit the examination locally at their home institutions. It will be a three-hour proctored test of 150 multiple-choice questions, to be given between the dates of Thursday, February 16, 2012, and Monday, February 20, 2012. Training directors may set the specific time and date of the examination at their sites.

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The fee for the examination is $125 per candidate. The registration deadline is January 20, 2012, and payment must be received by February 1, 2012. Registrations received after the January 20 deadline will be subject to a $10 per candidate late fee. To register, return the registration form with the list of all candidates for the exam. If you have any questions, please contact the ACNS Executive Office at email: ACNS@ssmgt.com or phone: 860-243-3977.

Click here for the Inservice Exam Registration Form.

ACNS Membership If you are not presently a member of the ACNS, please consider joining. Membership benefits include reduced fees for CME-accredited meetings and courses, reduced dues for members in training and early practice physicians, a subscription to the Journal of Clinical Neurophysiology and MORE! For additional information on ACNS and the benefits of membership, please visit the ACNS website: www.acns.org.

American Clinical Neurophysiology Society One Regency Drive P.O. Box 30 Bloomfield, CT 06002 Phone: 860-243-3977 Fax: 860-286-0787 E-mail: ACNS@ssmgt.com Website: www.ACNS.org

ACNS Newsletter January 2012  

ACNS Newsletter January 2012, Volume 4 Issue 1

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