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Submit IOM Data
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I Acknowledge and Agree.
Submitter's Email
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Date of Surgery
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Patient's Last Name
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Surgery/Procedure
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Facesheet
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Chat Log
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Pre-Op H and P
Start Time
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05:00 a.m.
05:30 a.m.
06:00 a.m.
06:30 a.m.
07:00 a.m.
07:30 a.m.
08:00 a.m.
08:30 a.m.
09:00 a.m.
09:30 a.m.
10:00 a.m.
10:30 a.m.
11:00 a.m.
11:30 a.m.
12:00 p.m.
12:30 p.m.
01:00 p.m.
01:30 p.m.
02:00 p.m.
02:30 p.m.
03:00 p.m.
03:30 p.m.
04:00 p.m.
04:30 p.m.
05:00 p.m.
05:30 p.m.
06:00 p.m.
06:30 p.m.
07:00 p.m.
07:30 p.m.
08:00 p.m.
08:30 p.m.
09:00 p.m.
09:30 p.m.
10:00 p.m.
10:30 p.m.
11:00 p.m.
11:30 p.m.
12:00 a.m.
12:30 a.m.
01:00 a.m.
01:30 a.m.
02:00 a.m.
02:30 a.m.
03:00 a.m.
03:30 a.m.
04:00 a.m.
04:30 a.m.
Stop Time
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05:00 a.m.
05:30 a.m.
06:00 a.m.
06:30 a.m.
07:00 a.m.
07:30 a.m.
08:00 a.m.
08:30 a.m.
09:00 a.m.
09:30 a.m.
10:00 a.m.
10:30 a.m.
11:00 a.m.
11:30 a.m.
12:00 p.m.
12:30 p.m.
01:00 p.m.
01:30 p.m.
02:00 p.m.
02:30 p.m.
03:00 p.m.
03:30 p.m.
04:00 p.m.
04:30 p.m.
05:00 p.m.
05:30 p.m.
06:00 p.m.
06:30 p.m.
07:00 p.m.
07:30 p.m.
08:00 p.m.
08:30 p.m.
09:00 p.m.
09:30 p.m.
10:00 p.m.
10:30 p.m.
11:00 p.m.
11:30 p.m.
12:00 a.m.
12:30 a.m.
01:00 a.m.
01:30 a.m.
02:00 a.m.
02:30 a.m.
03:00 a.m.
03:30 a.m.
04:00 a.m.
04:30 a.m.
Insurance Type
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Medicare
Non-Medicare
Common Modalities
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EEG - 95822-26:1 or 95955-26:1
Train-of-Four
Limb EMG (2 limbs) - 95861-26:1 or 95870-26:2
Limb EMG (4 limbs) - 95864-26:1 or 95870-26:4
Nerve Proximity Testing (Lateral Lumbar)
Pedicle Screw Stimulation
SSEP UE - 95925-26:1
SSEP LE - 95926-26:1
SSEP UE+LE - 95938-26:1
MEP UE - 95928-26:1
MEP LE - 95929-26:1
MEP UE+LE - 95939-26:1
None of the Common Modalities
Other Modalities
Vocalis EMG - 95865-26:1
Anal Sphincter EMG - 51785-26:1
CN EMG - 95867-26:1 or 95868-26:1
Low-Current Direct Nerve Stim
BAER - 92585-26:1
VEP - 95930-26:1
Other
Other
CN EMG Muscles
Inferior Rectus (CN III)
Superior Oblique (CN IV)
Lateral Rectus (CN VI)
Masseter (CN V)
Mentalis (CN VII)
Orbicularis Oculi (CN VII)
Nasalis (CN VII)
Orbicularis Oris (CN VII)
Soft Palate (CN IX)
Vocalis (CN X)
Tongue (CN XII)
Trapezius (CN XI)
Other
Other
Limb EMG Muscles
Trapezius (C3-4)
Deltoid (C5-6)
Biceps brachii (C5-6)
Triceps brachii (C6-8)
Flexor Carpi Radialis (C6-7)
Flexor Carpi Ulnaris (C7-T1)
Abductor Digiti Minimi (C8-T1)
Abductor Pollicis Brevis (C8-T1)
Biceps Femoris (L5-S2)
Psoas Major (L1-3)
Gracilis (L2-3, Obturator nerve)
Rectus Femoris (L2-4, Femoral nerve)
Vastus Medialis (L2-3, Femoral nerve)
Vastus Lateralis (L3-4, Femoral nerve)
Tibialis Anterior (L4-5)
Lateral Gastrocnemius (L5-S1)
Medial Gastrocnemius (S1)
Abductor Hallucis (S1-3)
Other
Other
Trunk EMG Muscles
Vocalis (RLN)
Rectus Abdominis (T7-12)
External Obliques (T7-12)
Anal Sphincter (S2-4)
Other
Other
Tech Notes
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