Neurology & Pain Management Coding Alert

Parkinsons (332.0) sufferers often exhibit symptoms including uncontrollable severe writhing and violent movements that can propel them out of chairs. These symptoms ultimately can leave patients unable to care for themselves. Treatment of Parkinsons disease with drugs such as Ropinirole (also known as Requip) or Pramipexole (or Mirapex) often is not effective in helping to regulate the diseases debilitating symptoms and affording patients a better quality of life. Recent studies have indicated that early and prolonged use of Levodopa (L-dopa) actually may cause the premature onset of some of the more extreme symptoms.

Bill for Stimulator Programming

Implanting deep brain stimulators to control these symptoms occasionally is necessary. Neurologists often work hand-in-hand with neurosurgeons performing surgical interventions for Parkinsons disease, with the neurologists handling the programming of the deep brain stimulators.

But a controversy exists concerning reimbursement for programming or adjusting these stimulators, a process that is done in the wake of the implantation surgery and may take as much as six hours in selected cases and involve multiple sessions with the patient.

Richard Roski, MD, American Medical Association (AMA) CPT advisor for the American Association of Neurological Surgeons and a neurosurgeon who treats Parkinsons patients at Quad City Neurosurgical Associates, a center with five neurosurgeons in Davenport, Iowa, says that from the perspective of many insurance carriers, reimbursement for programming these stimulators has nothing to do with the amount of time a neurologist may have to invest.

The argument is that with a simple generator, the neurologist may only adjust a limited number of variables and so there is an assumption that limited time will be spent, and a low flat rate is applied, Roski says. If multiple variables are involved, such as four or more, then the process is designated complex and may be billed in time increments provided reprogramming is involved.

Drawing the Line Between Simple and Complex

CPT 2000 says a simple neurostimulator (95970, 95971) is one capable of affecting 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, more than one clinical feature (e.g., rigidity, dyskinesia, tremor). A complex neurostimulator (95972, 95973, 95974, 95975) is one capable of affecting more than three of the above.

Erwin Montgomery, MD, director of the movement disorders program from the Cleveland Clinic in Cleveland, which has more than 40 neurologists on staff, says that Medicare, the AMA and many insurance companies have taken the position that adjusting deep brain stimulators is a simple process and very little distinction is being made between the treatment of essential tremor and Parkinsons disease. He reports that now, the AMA has approved only the deep brain stimulation of the thalamus for tremors. He is hopeful that the federal Food and Drug Administration will review the situation and approve deep brain stimulation of the subthalamic nucleus and the globus pallidus.

Many physicians are reluctant to offer their patients this treatment because they know theyre not going to be reimbursed at an appropriate level for the amount of work they have to do, Montgomery reports.

Shirley Triche, RN, nurse to Mahlon R. DeLong, MD, chairman of the neurology department at the Emory Clinic in Atlanta, says that although the programming of deep brain stimulators for the treatment of tremors may be considered simple, the programming of deep brain stimulators for treatment of Parkinsons disease is much more complex. You cannot consider programming for Parkinsons as simple because it requires much more time than a patient being treated for tremors. We bill the complex time-based codes, Triche says.

Jerrold Vitek, MD, PhD, director of functional neurological procedures for Emory Clinic in Atlanta, one of the largest Parkinsons centers in the country, stresses that it is important to let a carrier know when programming a deep brain stimulator for a Parkinsons sufferer meets the CPT requirements for a complex adjustment because four of the listed criteria that must be affected are met: pulse amplitude, pulse duration, pulse frequency, and more than one clinical feature. With Parkinsons disease, the physician 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.

Coding Parkinsons Treatment 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 95974: complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour 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)