Anesthesia Coding Alert

Question: We use 63650 to report a trial implant of neurostimulator electrodes. This code has a 90-day global period. Are follow-up visits included in the global period? How should we bill for follow-up visits when the patient does not have a permanent neurostimulator implanted and we still have to find alternative treatment for the pain? And is there any other CPT code besides 63650 for the trial implant that does not have a 90-day global period?

Arkansas Subscriber 

 
Answer: Code 63650 (percutaneous implantation of neurostimulator electrode array, epidural) should be used both for trial and permanent neurostimulator implants, says Devona Slater, CMCP, a pain management coding and reimbursement specialist in Leawood, Kan. That does not mean that the follow-up visits are included in the procedure's global period.
 
Because the visits to find alternative ways to treat the patient's pain are unrelated to the original procedure, modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) should be appended to the appropriate subsequent visit code. Any subsequent procedure performed within the global period of 63650 (for example, if the physician determines the patient requires alternative treatment) may also be billed separately by attaching modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to the second procedure. By using this modifier, the physician indicates that the procedure was either preplanned or is related to the implantation of the stimulator but is not a complication.
 
Note: Modifier -58 should also be used if the permanent neurostimulator is installed during the global period of the original implantation of the trial stimulator. In that case, the same code used to bill for the trial stimulator, 63650, should be billed again, this time with modifier -58 attached.
 
If the visit relates to a problem with the temporary stimulator itself or its implantation (i.e., an infection), the visit is included in the global period unless it requires a return to the operating room, in which case modifier -78 (return to the operating room for a related procedure during the postoperative period) should be appended.
 
According to Prescription for Pain Billing (PPB), which was co-authored by Slater, "The importance of preauthorization cannot be stressed enough. This procedure is very expensive, and to assure payment for services rendered preauthorization must be obtained from most third-party payers."
 
Most Medicare carriers pay for this service. But documentation must be present in the patient's medical record to show that all criteria for patient selection have been met (i.e., indications and/or diagnoses), according to PPB, which cautions that Medicare carriers may even conduct a prepayment review before paying physicians for some neurostimulator services.
 
Note: To order Prescription for Pain Billing, co-authored by Devona Slater, CMCP, contact ACE Inc. at 913-648-8572.