# Two sprinal cord generator implants



## celcano (Jul 15, 2015)

This is the first time I have run across this scenario since I began pain management coding.  My physician did the following procedures in the same session:
Insertion of a permanent midline cervical octrode spinal cord stimulator lead
Insertion of a permanent life cervical octrode spinal cord stimulator lead
Insertion of a permanent right thoracic octrode spinal cord stimulator lead
Insertion of a permanent left thoracic octrode spinal cord stimulator lead
Implantation of left power spinal cord generator
Implantation of right power spinal cord generator
Intraoperative neurostimulation trail

Code 63650 has an MUE of 2 and code 63685 has a MUE of 1.  The physician billed 4 units of 63650 and 2 units of 63685.  Of course, these have hit billing edits because the units exceed the MUEs.

My thoughts on billing this is:
63650 X 2
63650-59 X 2
63685 X 1
63685-59 X 1
95972 (MUE of 1.  Would I bill total time spent for the intraoperative neurostimulation trial for both generators/leads or bill for 2 separate line items?)

Any guidance would be greatly appreciated.


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## dwaldman (Jul 16, 2015)

Neurostimulator Analysis & Programming: The AMA CPT has defined simple intraoperative or subsequent programming of neurostimulator pulse generator with code 95971 when there are changes to three or fewer of the following parameters: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time, or more than one clinical feature. Complex intraoperative or subsequent programming is defined as changes in more than three of the parameters above (codes 95972-95973). 

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Above is from the below link and they point out that to bill complex programming under 95972, the medical documentation would have to support that there was  changes/programming  of more than three parameters. And this would not be reported if performed by the manufacturer's representative.

http://hcp.controlyourpain.com/reimbursement/

Like you stated Medicare has medically unlikely edit (MUE) of a maximum of number of leads for CPT 63650. They also allow one unit of service for the pulse generator placement (63685). What is being described without seeing the operative report makes me question if these leads were placed in the epidural space to represent a dorsal column/spinal cord stimulator or if this is percutaneous subcutaneous field stimulation which falls under 0283T for the leads and IPG placement. And 0285T if documented being actually performed by the physician. Below I have provided from AMA CPT Changes 2012, the use of the category III codes for percutaneous subcutaneous field stimulation.  

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0283T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; permanent, with implantation of a pulse generator

0285T Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed 
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AMA CPT Changes 2012

Four Category III codes have been established for reporting peripheral field stimulation. Peripheral field stimulation is a new technology for the treatment of chronic cervical, thoracic, or lumbar pain. Electrode leads are placed in subcutaneous tissue around the painful area, and electrical current is applied to create stimulation in the area, or "field," of pain. This technique is different from peripheral nerve stimulation, in which specific peripheral nerves are targeted. In peripheral field stimulation, a field of pain is targeted rather than specific nerves. The electrodes are placed in the skin either through an open or percutaneous approach. Imaging guidance is included, when performed.

Code 0282T describes implantation of trial electrode arrays and includes removal of the electrodes at the end of the trial period. Code 0283T is reported for permanent implantation of electrode arrays with implantation of a pulse generator. Revision or removal of the pulse generator or electrodes is reported with code 0284T and includes addition of new electrodes, when performed. Code 0285T describes electronic analysis of the pulse generator and includes reprogramming, when performed. An exclusionary parenthetical note precludes the reporting of codes 0282T - 0285T with the peripheral nerve neurostimulator codes 64550 - 64595, fluoroscopic guidance codes 77002 and 77003, or electronic analysis of neurostimulator pulse generator codes 95970 - 97973.


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## celcano (Jul 16, 2015)

Thank you.  I will review with my physician.


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