Anesthesia Coding Alert

Categorize to Prove Medical Necessity

Just because neurostimulation might improve the patient's chronic pain, coding won't always be simple and reimbursement is never guaranteed. Many carriers classify diagnoses as "medically appropriate," "medically necessary" or "investigational." Knowing where your patient fits can help your coding efforts.

Before coding neurostimulation procedures, first confirm that your documentation proves the physician's previous treatment attempts and that those treatments were ineffective. Thorough documentation helps show that neurostimulation is a necessary last resort to relieve the patient's pain.

Carriers are more likely to consider charges for medically necessary services, but the carrier's SCS policy might not list many conditions that justify treatment. For example, Blue Cross/Blue Shield of Tennessee lists only three conditions that support medical necessity for neurostimulation:

Even if the carrier's policy includes the patient's condition on its list of approved diagnoses, Isom still recommends obtaining certification before scheduling the procedure.

If your carrier considers the stimulator placement investigational, you should ask the patient to sign an advance beneficiary notice before scheduling the procedure, Isom says. Some carriers list neurostimulator use as investigational for the following conditions:

Choose Among Implantation, Reprogramming Codes

The term "neurostimulation" encompasses a range of procedures, depending on the pain location and the best treatment route. Once you verify that the patient's condition qualifies for neurostimulation, your next step is understanding and correctly coding the actual treatment.

Neurostimulation treatments are divided into three groups, based on the part of the nervous system that the physician treats (see page 4 for more on neurostimulation for the peripheral and sympathetic nervous systems).

The brain and spinal cord make up the central nervous system (CNS), and spinal cord stimulation falls into this area, says David Walega, MD, assistant professor of anesthesiology and director of the Anesthesiology Pain Medicine Center at NMFF in Chicago.

Physicians use neurostimulation to treat central nervous system conditions such as post-thalamic stroke syndrome (348.8, Other conditions of brain) and Parkinson's disease (332.0, Paralysis agitans). Codes 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) and 63655 (Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural) are the most common spinal cord stimulator codes. Report 63685 (Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling) for permanent pulse generator implantation.

Patients with SCS should return to your office monthly for pump reprogramming. If the physician doesn't make any programming changes, report 95970 (Electronic analysis of implanted neurostimulator pulse generator system [e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements]; simple or complex brain, spinal cord or peripheral [i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular] neurostimulator pulse generator/ transmitter, without reprogramming).

Choose 95971 (... simple brain, spinal cord, or peripheral [i.e., peripheral nerve, autonomic nerve, neuromuscular] neurostimulator pulse generator/ transmitter, with intraoperative or subsequent programming) if the physician reprograms the pump. If the stimulator is complex, report 95972 (... complex brain, spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour) for the first hour of subsequent reprogramming and +95973 (... complex brain, spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour [list separately in addition to code for primary procedure]) for each additional 30 minutes.

Spinal cord stimulation carries a 90-day global period, so be sure to report modifier -58 (Staged or related procedure or service ...) with the appropriate procedure code the first time the patient returns to your office for reprogramming, assuming it is within that global period.

Account for the Other Physicians

If a pain management specialist in your group performs the neurostimulation procedure, don't forget that another member of the group will also submit a claim as the procedure's anesthesiologist. Report the anesthesia according to the spinal area treated and the surgical code reported. Anesthesia codes you'll use most often include:

Alternative anesthesia codes include 00600 (Anesthesia for procedures on cervical spine and cord; not otherwise specified) and 00620 (Anesthesia for procedures on thoracic spine and cord; not otherwise specified).

"Ensuring that another member of the anesthesia group provides sedation is one of my biggest challenges with neurostimulator coding," Isom says. "Documentation of these cases can't be stressed enough, whether you're documenting medical necessity, certification of coverage, or the procedure itself."