Neurology & Pain Management Coding Alert

Treatment for Parkinson's disease may include implantation of deep brain stimulators, which must be programmed and adjusted. This time-intensive service alleviates the disease's debilitating symptoms and improves the quality of life for sufferers, but can result in disproportionately low reimbursement. But, physicians can guarantee the highest-available compensation by communicating with payers and providing thorough documentation of all stimulus parameters adjusted.

Patient's undergoing treatment for Parkinson's disease often receive drugs such as Levodopa (L-dopa), Pramipexole (also known as Mirapex) or Ropinirole (a.k.a. Requip) to control tremors and other symptoms. If drugs are ineffective, the patient may be treated surgically, which can include cranial placement of deep brain stimulators (DBS), 61850-61886. DBS use electrical stimulation of specific deep brain structures via tiny implanted electrodes and may be programmed for optimal results, says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.
 
As explained by the local medical review policy (LMRP), # 99.07, for Blue Cross/Blue Shield of North Dakota (BCBSND), the Part B carrier for Colorado, North Dakota, South Dakota and Wyoming, "Since patients require some time to build up tolerance for optimal stimulation, the pulse generator needs to be programmed/analyzed or adjusted at a more frequent level in the first 18 months of use. Typically, the generator is programmed intraoperatively, 'ramped up' two weeks later, and adjusted thereafter until optimal efficacy is achieved." A surgeon places the DBS unit, while a neurologist often provides subsequent adjustments.
 
Note: According to LMRP #00-7 of the National Heritage Insurance Company (NHIC), the Part B provider for Texas, coverage for DBS "is for IPD (idiopathic Parkinson's disease) that has unequivocally responded to pharmacological treatment and became refractory or for which pharmacological response has been poor." Other carriers specify similar guidelines.

CPT and Part B Medicare carrier LMRPs list four codes to report analysis and/or reprogramming of the DBS unit. Note that 63690 and 63691, previously used to report these services, were deleted as of Jan. 1, 1999.
 

  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
 

95971 simple brain, spinal cord, or peripheral (i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming
 

95972 complex brain, spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour
 

95973 each additional 30 minutes after first hour (list separately in addition to code for primary procedure).

Note: CPT states that the codes for surgical implantation of the DBS unit (61850-61886) do not include evaluation, testing, programming or reprogramming. Therefore, the neurologist may provide and bill separately for these services immediately following the implantation. However, BCBSND LMRP #99.07 dictates, "Adjustments during the initial 90 days after implantation are considered to be part of the global period." Check with the individual payer before billing these services during the surgical global period.
 
According to CPT, a simple neurostimulator (e.g., 95970 and 95971) controls three or fewer of the following stimulus parameters: pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, phase angle, alternating electrode polarities, configuration of wave form or more than one clinical feature. A complex neurostimulator (e.g., 95972 and 95973) affects more than three of the above. Programming of the unit may require as much as six hours and could include several sessions, says Richard Roski, MD, AMA CPT adviser for the American Association of Neurological Surgeons and a practicing neurosurgeon at Quad City Neurosurgical Associates in Davenport, Iowa.
 
NHIC's LMRP, policy #00-7, further specifies, "The distinction among the neurostimulator programming codes (95970-95973) is predicated on the manipulated number of parameters, both electrical and clinical. Attention to these variables and the time spent on programming are crucial determinants to qualify for the appropriate code."
 
When reprogramming the DBS unit for Parkinson's sufferers, pulse amplitude, pulse duration, pulse frequency and more than one clinical feature (e.g., dyskinesia, muscular rigidity, hypokinesia, dystonia and/or tremor) are generally adjusted, which allows reporting of the "complex" codes, 95972 and 95973, Sandham says. These time-based codes reimburse at a much better rate than 95970 and 95971 (0.65 and 1.13 relative value units [RVUs] for 95970 and 95971, compared to 2.3 and 1.39 RVUs for 95972 and 95973), and allow the neurologist to receive compensation for his or her time.
 
Note: 95973 is an add-on code that can be applied only after the first hour. Do not append modifier -51 (multiple procedures) to 95973.

Documentation must clearly support the code selection by listing the number of stimulus parameters addressed. Generally, DBS units used for treatment of essential tremors (as opposed to tremors that arise as a result of Parkinson's) are "simple," and reprogramming must be reported with 95970 or 95971. Communicate with the payer, letting it know that reprogramming a DBS unit for Parkinson's patients is more complex than that for simple treatment of tumors, and the adjustment in this case is for treatment of Parkinson's, Roski says. Always be sure to attach the diagnosis code for Parkinson's 332.0 to the claim.
 
Note: If fewer than three stimulus parameters are addressed or documented during the reprogramming, the "simple" codes must be reported no matter how much time was needed to complete the service.
 
According to NHIC and other local carriers, if medical necessity is demonstrated, programming codes (95970-95973) "will be reimbursed at a frequency of every 30 days." However, BCBSND's LMRP further specifies, "Billing any of the 9597x procedure code series after the first analysis/programming session will require submission of supporting documentation for the necessity of the service." This would include evidence of worsening symptoms (e.g., rigidity), which should be documented using the appropriate ICD-9 codes, or demonstrated adverse effects from the current neurostimulator settings.