Anesthesia Coding Alert

Correctly coding and getting reimbursed for dual leads hinges on appropriate documentation up front, experts explain.

Patients with chronic, neuropathic pain may be treated with spinal cord stimulators to increase their comfort and quality of life. Pain management practices are treating increasing numbers of these patients.

Problems sometimes arise when the patient is treated for pain in the back or lower extremities, and more than one lead of electrodes is needed for the procedure. For example, the patient may need leads for both legs, or for one leg and another area, because a single lead isnt long enough to cover the necessary area.

A single lead or catheter has eight electrodes on it, says Brenda Lomenick, office manager of Specialists in Pain Management in Chattanooga, TN. Thats fine for most of our patients, but not for all of them. Were treating more and more patients who need multiple leads to cover the area for adequate pain relief, and some carriers dont recognize that fact.

As a result, these carriers deny reimbursement for one of the leads, saying that the physician is double charging for the service. Lomenick and Michelle Skogstrana, billing supervisor of Pain Consultants of the Rockies in Cheyenne, WY., say the denials occur because the current CPT code 63650 (percutaneous implantation of neurostimulator electrode array, epidural) is based on a collection of electrodes instead of the lead as a single unit.

We code the procedure as 63650 for each lead used, says Skogstrana, because thats the right code for it. Sometimes were reimbursed for everything, and sometimes were not. It depends partly on the carrier and even partly on the representative you speak to at the carriers office. You may get lucky and talk to someone who understands the situation and will send the claim through without any problems.

Skogstrana thinks part of the reason carriers are more attuned to charges for electrode leads is because some physicians and billing personnel have taken advantage of the situation in the past. If you interpret the CPT definition literally, it seems like the code is for a single electrode. Anyone who is familiar with coding knows you bill by the lead, not the electrode, and that the code is really for one string, or set, of electrodes. But some people were taking the definition literally and billing it eight timesone for each electrode. I think thats part of the reason why carriers are so leery of reimbursing for dual leads-they think youre trying to slip a double charge through the system.

Billing for Complete Reimbursement

Lomenick explains, The procedure must be dictated correctly and the notes must be clear that two separate leads are being used. The physicians dont always take the time to write thorough operative reports, and having just a little more detail in them can make the difference between getting paid for the second lead or having the claim denied.

Most Medicare carriers will reimburse for both leads as long as the procedure report includes the proper documentation. The report must have notes from the technologist who programs the leads about the specific type and number of leads that were used, as well as documentation by the physician.

Even with proper documentation, payment for the second lead is usually about half the normal payment for the original lead, says Lomenick. But getting paid a little for it is better than not getting paid at all.

Working with the Carriers

Many managed-care organizations routinely deny payment for more than one lead. Skogstrana and Lomenick agree that the best way to deal with the situation is to completely document the procedure and continue working with the carriers to educate them about the medical necessity of sometimes using multiple leads.

New Jersey Manufactures (NJM), an insurance company that has been seeing more claims for dual leads in the past year, decided to get an official determination from the American Medical Association (AMA) on the use of code 63650. Since then, NJM has approved claims for dual leads with no questions asked as long as the case is thoroughly documented.

Pain management is a growing sub-specialty of anesthesia, and situations like this will become even more frequent, Skogstrana says. Being able to tell carriers that AMA approves of paying for both leads makes reimbursement a little easier, but we hope the code is further defined in future editions of CPT. In the meantime, the best option is to continue educating our local carriers and fighting for one case at a time.