Neurology & Pain Management Coding Alert

Trials and reprogramming can help you to recover your deserved payment for these services.

Your chances of successfully reporting your neurologist's spinal neurostimulator implant services will improve dramatically if you can capture all the steps in the operative note. Correctly assigning codes depends on identifying a typical sequence, which includes placing a trial electrode array/lead, removing it, implanting a permanent electrode array/lead and pulse generator, and lastly programming the generator system at regular intervals according to the clinical response.

Code for Each Trial Array

Most patients will be subjected to a trial before they are given permanent spinal cord stimulator. "Trial placement of electrodes is done to make sure a patient can tolerate it before a permanent one is placed," says Teresa Thomas, BBA, RHIT, CPC, practice manager II, St. John's Clinic -- Neurosurgery, Springfield, Missouri.

The trial placement helps to test and confirm the relief from pain. "The trial helps to determine if spinal cord stimulation provides relief to the patient prior to performing a more invasive procedure," explains Gwendolyn M. Flaherty, CPC, NeuroScience Associates, Idaho. "The trial helps to assure that the neurostimulator will be beneficial to the patient," says Marilyn Glidden, CPC, NeuroScience and Spine Associates, Naples, Florida. You should be specific in the number of electrode arrays that were placed and code for each of them.

Example: If, in bilateral leg pain, the surgeon percutaneously places two electrode arrays in the epidural space for trial neurostimulation, you code one unit of service of 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) for each of the trial array placement. "Some payers may allow you to report this as a single line item with two units of service while others may prefer that you report the two trial array placement be reported as two separate line items. You will likely need to differentiate the two line items with an appended modifier such as 51 (Multiple procedures)," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

You may further read that when the patient returns a week later, the surgeon disconnected the external neurostimulator and removed the trial arrays at the second visit. "The work of removing a temporary percutaneous electrode array is included in the code for the 'initial' trial placement. Per the CPT® section guidelines, it would not be appropriate to separately report CPT® code 63661 (Removal of spinal neurostimulator electrode percutaneous array[s], including fluoroscopy, when performed) for the removal of the percutaneous trial electrode arrays," says Hammer.

If the patient had positive results from the trial stimulator, the pain management provider may determine that the patient is a candidate for a permanent spinal cord stimulator system. "It is important to check the payer's coverage policy requirements as the indications and percentage of relief required to support a permanent placement varies between payers. If the payer's coverage policy requirements are met, the pain management specialist may proceed with percutaneous implantation of the permanent electrode arrays," says Hammer.

There currently is not a separate CPT® code for trial versus permanent placement. You would again report code 63650 for the permanent percutaneously placed electrode array and 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling) for the new pulse generator implanted. If the physician decides to perform a laminectomy to place a permanent electrode plate or paddle for the spinal code stimulation, rather than using the percutaneous approach, you would report 63655 (Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural) instead of 63650.

Remember: Additionally, you may need to append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period.....) to 63650 and 63685 in the example above if they were performed during the postoperative period of the initial trial percutaneous array insertions.

You will need to be careful as the global period is different for the two surgical approaches for implantation of the electrodes. "Surgical codes can have a 0, 10 or 90 global period," says Flaherty. "CPT® codes 63650 and 63685 have a 10-day period whereas the 63655 code has a 90-day global period because it requires the more invasive laminectomy," says Hammer.

Caution: The epidural electrode arrays may be placed under fluoroscopic guidance but you do not report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid]) in addition to 63650 as the Correct Coding Initiative (CCI) bundles the two. "Fluoroscopy is bundled into 63650," affirms Flaherty. "CCI edits tell you not to bill separately," confirms Glidden.

Analysis and programming is not a part of the global period. "Programming can be performed on the day of the surgical procedure and/or during the post-operative period. The frequency may decline after the patient is 'stabilized' on the settings and/or is trained to use the stimulator programmer by himself," says Hammer.