Neurology & Pain Management Coding Alert

Don't risk losing allowable reimbursement

If your neurologist uses neurostimulation to treat patients- chronic pain, confirm that your patients meet their carriers- medical-necessity requirements before performing the procedures.

Many carriers still consider neurostimulation to be investigational for some diagnoses, so get your carriers- policies in writing and keep an ABN (advance beneficiary notice) nearby just in case.

Categorize Diagnoses to Prove Medical Necessity

Just because neurostimulation (also known as spinal cord stimulation, or SCS) might improve the patient's chronic pain doesn't guarantee easy coding or assured reimbursement.

Many carriers classify diagnoses as -medically appropriate,- -medically necessary- or -investigational.- Knowing which category the patient's condition falls into can help your coding efforts.

Check documentation: Before coding neurostimulation procedures, verify that you have documentation of previous treatments to prove to the carrier that your physician tried other treatment methods--but they were ineffective. This documentation helps show that the patient needs neurostimulation treatment as the last effort to relieve his pain, says Darlene Isom, a billing supervisor at Northwestern Medical Faculty Foundation Inc. (NMFF) in Chicago.

Always check the carrier's SCS policy for neurostimulation because the payer might have a short list of conditions justifying treatment. Example: Common conditions that support medical necessity for neurostimulation include:

- Radiculopathies (diseases involving the nerve roots, including failed back surgery syndrome, arachnoidis and epidural fibrosis)--many diagnoses fall under this umbrella, including codes 729.2 (Neuralgia, neuritis, and radiculitis, unspecified) and 322.9 (Meningitis, unspecified).

- Reflex sympathetic dystrophy (also known as complex regional pain syndrome type 1)--select the appropriate code from 337.20-337.29 (various sites for Reflex sympathetic dystrophy).

- Intractable pain from severe peripheral vascular disease (PVD)--code the patient's type of pain first, with the PVD as a secondary condition (443.9, Peripheral vascular disease, unspecified; 747.64, Other anomalies of peripheral vascular system; lower limb vessel anomaly; or 747.69, Anomalies of other specified sites of peripheral vascular system).

Even if the carrier's policy includes the patient's condition on its list of approved diagnoses, Isom still recommends obtaining certification before scheduling the procedure.

Cover Your Bases With an ABN

If, on the other hand, the carrier considers the stimulator placement investigational, ask the patient to sign an ABN before scheduling the procedure, Isom says. Some carriers consider neurostimulator use as investigational for conditions such as:

- Intractable angina--413.9 (Other and unspecified angina pectoris)

- Plexus lesions caused by trauma or malignancy--353.0-353.9 (various locations of nerve root or plexus lesions or disorders), 722.x series (Intervertebral disc disorders), 720.x (Ankylosing spondylitis and other inflammatory spondylopathies), 721.x (Spondylosis and allied disorders), 723.x (Other disorders of cervical region) or 724.x (Other and unspecified disorders of back)

- Multiple sclerosis--340 (Multiple sclerosis)

- Neuropathy due to injuries, surgery, entrapment or scars--codes such as 355.9 (Mononeuritis of unspecified site)

- Postamputation pain--353.6 (Phantom limb [syndrome])

- Postherpetic neuralgia--053.12 (Postherpetic trigeminal neuralgia), 053.13 (Postherpetic polyneuropathy) or 053.19 (Herpes zoster; with other nervous system complications; other).

Choose From Implantation, Reprogramming Codes

The term -neurostimulation- encompasses a range of procedures, depending on the pain location and the best treatment route. Once you verify that the patient's condition qualifies for neurostimulation, your next step is understanding and correctly coding the actual treatment.
 
Neurostimulation treatments are divided into three groups, based on which part of the nervous system the physician treats. Spinal cord stimulation falls under treatments of the central nervous system (the brain and spinal cord), says David Walega, MD, of the Anesthesiology Pain Medicine Center at NMFF.
 
Initial treatment: Physicians use neurostimulation to treat central nervous system conditions such as post-thalamic stroke syndrome (348.8, Other conditions of brain) and Parkinson's disease (332.0, Paralysis agitans).
 
The most common codes for spinal cord stimulator placement are 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) and 63655 (Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural). Report 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling) for permanent implantation of the pulse generator.

Follow-up care: Patients with SCS then return to your office monthly for pump reprogramming. If your physician doesn't make any programming changes, report 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).
 
Report 95971 (- simple brain, spinal cord, or peripheral [i.e., peripheral nerve, autonomic nerve, neuromuscular] neurostimulator pulse generator/transmitter, with intraoperative or subsequent pro-gramming) if the physician reprograms a simple SCS.
 
If the stimulator is complex, report 95972 (- complex brain, spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour) for the first hour of subsequent reprogramming and +95973 (- complex brain, spinal cord, or peripheral [except 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.

Modifier note: Spinal cord stimulation carries a 90-day global period, so be sure to report modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) with the appropriate procedure code the first time the patient returns to your office for reprogramming.

-The importance of documenting these cases can't be stressed enough, whether you-re documenting medical necessity, certification of coverage, or the procedure itself,- Isom says.

Even if you have prior certification, Isom recommends that you always send the physician's notes to the carrier as a follow-up to help move reimbursement along.

-Medicare providers continue to face obstacles with obtaining treatment for SCS,- she says. -Hopefully, more published research on neurostimulation and implementation of permanent codes related to the procedure will help more carriers accept SCS as a valuable tool to treat chronic pain.-