Neurology & Pain Management Coding Alert

To receive just compensation, neurologists reporting analysis and/or programming of implanted neurostimulators must document all of the stimulus parameters adjusted, as well as observe frequency limitations imposed on these services. Fortunately, a quick review of payer and CPT requirements can provide all the necessary guidance.

A neurostimulator pulse generator system is a surgically implanted, pacemaker-like device that delivers preprogrammed intermittent electrical pulses to a particular nerve(s) or brain structure(s). Neurologists use this system to treat several conditions that do not respond satisfactorily to medication alone, including Parkinson's disease, epileptic seizure, urinary urge incontinence and others.

A physician, usually a neurologist, typically tests the device and leads and sets the initial programming parameters, both in the operating room and in the office setting during the days and weeks following the implant, says Petrina White, CPC, coding specialist in the department of neurosurgery at Vanderbilt University Medical Center in Nashville, Tenn. For example, a typical Medicare local medical review policy (LMRP) explains, "[Because] 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."

The appropriate analysis/reprogramming code depends on the type and location of the pulse generator, which in turn depends on the patient's condition. For example, report neurostimulator reprogramming/analysis for vagal nerve stimulation (to treat refractory epileptic seizure) or sacral nerve stimulation (for urinary urge incontinence) as 95970, 95974 or 95975. Code the same service for deep brain stimulation (DBS) to treat Parkinson's disease as 95970, 95971-95973, depending on circumstances (see Neurostimulator Analysis/Programming Codes on page 19 for descriptors).

Applicable ICD-9 codes and coverage limitations vary by payer and condition, but you will generally report the same diagnosis that provided justification for the pulse generator's implantation, says Frank Falco, MD, an AMACPTeditorial board member representing the American Academy of Physical Medicine and Rehabilitation. For instance, if the neurosurgeon cites a diagnosis of 345.51 (Partial epilepsy, without mention of impairment of consciousness, with intractable epilepsy, so stated) when reporting implantation (61850-61886), you may link 345.51 to 95974 to show medical necessity for programming.

According to the typical local Medicare carrier policy, if you can demonstrate medical necessity, programming codes (95971-95975) "will be reimbursed at a frequency of every 30 days." However, Blue Cross Blue Shield North Dakota (BCBSND) #99.07 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 (for example, rigidity) or demonstrated adverse effects arising from the current neurostimulator settings.

CPT states that the codes for surgical implantation of a pulse generator do not include evaluation, testing, programming or reprogramming. WPS Medicare Part B for Illinois and Michigan (policy NEURO-004), for example, states, "General practice is for the neurosurgeon alone to bill for the surgery Aseparate procedure code for electronic analysis services (CPT 95974 or 95975) may be appropriate if the neurologist/neurophysiology team adjusts and initiates initial stimulus levels in the operating room." Not all payers follow CPT guidelines, however. BCBSND's LMRP dictates, "Adjustments during the initial 90 days after implantation are considered to be part of the global period."

In addition, the national Correct Coding Initiative (CCI) and many Medicare LMRPs bundle simple analysis/programming to pulse generator placement but will allow you to bill separately for complex pulse generator programming. Because of the variability of coverage limitations and bundling issues, contact your individual carrier for its guidelines prior to billing.

A simple neurostimulator 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. Acomplex neurostimulator affects four or more parameters.

When reprogramming a DBS unit for Parkinson's sufferers, for example, the physician generally adjusts pulse amplitude, pulse duration, pulse frequency and more than one clinical feature (for instance, dyskinesia, muscular rigidity, hypokinesia, dystonia and/or tremor), which allows reporting of the time-based "complex" codes, 95972 and 95973. Typically, Falco says, complex reprogramming will not exceed 90 minutes.

Documentation must clearly support the code selection by listing the stimulus parameters addressed and time involved, or the payer may downcode the claim to "simple" status, resulting in lost reimbursement (for a sample documentation worksheet, see page 19). When documenting fewer than three stimulus parameters, you must report the "simple" codes no matter how much time the neurologist needs to complete the service.