Neurology & Pain Management Coding Alert

Distinguishing between simple and complex neurostimulator programming codes (95970-95975) is crucial for obtaining proper reimbursement. Understanding that insurance carriers do not always agree with the neurologists choice of codes is important, and you need to have the documentation to support it to fight reductions in payment. Correct coding is vital because of the great differences in relative value units (RVUs). For example, the RVU for a simple programming (95971) is 1.13 versus 4.47 for a complex one (95974).

In deciding which neurostimulator code to bill, you need to remember the difference between simple and complex programming:

A simple neurostimulator pulse generator/transmitter (95970, 95971) can affect three or fewer of the following: 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 (e.g., rigidity, dyskinesia, tremor).

A complex neurostimulator pulse generator/transmitter (95970, 95972, 95973, 95974, 95975) can affect more than three of the above areas.

For example, a Parkinsons disease (332.0) patient would meet the CPT requirements for complex programming because four of the listed criteria that are met: pulse amplitude, pulse duration, pulse frequency and more than one clinical feature. With Parkinsons disease, the neurologist can be addressing dyskinesia (781.3, distortion or impairment of voluntary movement), muscular rigidity, hypokinesia (780.9, abnormally diminished motor function or activity), dystonia (333.6, distortion of movements due to disordered tonicity of muscle) and tremor (781.0).

This would be coded as:

95974 ... complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour for the first hour of programming.

+95975 ... complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (list separately in addition to code for primary procedure) for each additional 30 minutes.

An example of simple neurostimulator programming is a patient who has a spinal neurostimulator installed for back-pain reduction and only three of the listed criteria that must be affected are met during the programming: pulse amplitude, pulse duration and pulse frequency.

This would be coded as:

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

Simple Versus Complex Programming

A controversy exists concerning reimbursement for programming neurostimulators, a process that may take as long as six hours and involve multiple sessions. Many carriers say reimbursement for programming has nothing to do with the amount of time a neurologist may have to invest, says Richard Roski, MD, AMA CPT advisor for the American Association of Neurological Surgeons and a neurosurgeon at Quad City Neurosurgical Associates, a center with five neurosurgeons in Davenport, Iowa. The argument is that with a simple neurostimulator, the doctor may only adjust a limited number of variables and there is an assumption that limited time will be spent, and a low flat rate is applied, he says. If multiple variables are involved, such as four or more, the process is designated complex and may be billed in time increments if reprogramming is involved. (Thus, the RVUs for complex programming are higher than those for simple programming.)

Medicare, the AMA and many insurance companies have taken the position that the programming of neurostimulators is a simple process, and very little distinction is being made between simple and complex. Many physicians are reluctant to offer this service because they know theyre not going to be reimbursed at an appropriate level for the amount of work they have to do, reports Erwin Montgomery, MD, director of the movement disorders program from the Cleveland Clinic in Cleveland, which has more than 40 neurologists on staff.

Because of this controversy it is important to let insurance carriers know exactly how many areas are being adjusted during the programming to demonstrate why it was complex versus simple. Montgomery suggests neurologists write a detailed letter explaining the benefits of the neurostimulator and the exact amount of time needed to program or reprogram, as well as what specific areas were adjusted. Neurologists should also make sure to document in the patients medical record how long the programming takes, to support the reasoning behind billing the complex code.