Neurology & Pain Management Coding Alert

Watch payer policies or watch your work get bundled into a surgical procedure

Nerve stimulation is a powerful treatment tool when medication alone does not produce adequate relief for your patients. But if you are unsure of how to report your analysis and programming of neurostimulators, you may be feeling the pinch of inadequate reimbursement.

The basics: 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 these systems to treat several conditions that do not respond satisfactorily to medication alone, including intractable pain in the trunk and/or limbs, arachnoiditis (322.9), peripheral neuropathy (356.0-356.9), Parkinson's disease (332.0), epileptic seizure (345.xx), urinary urge incontinence (788.31), and others.

The codes: See -Keep it in the Family: Your Shortcut to choosing accurate  Neurostimulator Codes- on page 35 for full descriptors of 95970-95979.

Follow these steps for worry-free coding of neurostimulator programming.

Overcome 3 Thresholds for Complex Neurostimulators

Before choosing the appropriate code from the 95970-95979 range, you-ll need to identify if you are dealing with a simple or complex neurostimulator.

If the system is used to stimulate the cranial nerve or involves deep brain stimulation, your choice is easy. In both of these cases, CPT will only allow you to use complex codes 95974-95979. But if you are faced with a spinal cord or peripheral neurostimulator, which are most commonly used, you-ll need to distinguish between simple and complex systems to select the appropriate code(s) from 95971-95973.

You need to decide by determining if you can clear the three-feature hurdle. According to CPT and American Academy of Neurology (AAN) guidelines, a simple neurostimulator is capable of affecting three or fewer of these features, while a complex neurostimulator is capable of affecting more than three:

- pulse amplitude
- pulse duration
- pulse frequency
- 8 or more electrode contacts
- cycling
- stimulation train duration
- train spacing
- number of programs
- number of channels
- alternating electrode polarities
- dose time (stimulation parameters changing in the time periods of minutes including dose lockout time)
- more than one clinical feature (e.g., rigidity, dyskinesia, tremor).

For example, a patient has a spinal neurostimulator for back-pain reduction. It affects pulse amplitude, pulse duration, and pulse frequency. In this case you would report 95971, because the neurostimulator is only capable of affecting three areas.

Important distinction: -The stimulation programming codes are based on what the system is capable of affecting and not on what parameters are being used for programming at any given programming session,- says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver.

Rule of thumb: In almost all cases you encounter today, you can expect that stimulators will have complex capabilities, says Eric Moser, MD, of High Point Neurological Associates in High Point, N.C. Simple stimulators really represent an older technology that is generally not being sold any longer, he adds.  

Keep Time on Your Side

Once you enter into the arena of complex neurostimulators, you will need to carefully consider your neurologist's notes, because billing for complex neurostimulation is always time-based. 

In addition to counting the minutes for programming itself, an FAQ provided by AAN states that you should also include face-to-face time spent with the patient, along with your time on the floor or unit waiting for the patient to respond and monitoring for side effects.

Documentation tip: You may want to ask your physicians to tally a total unit of service, such as 56 minutes, instead of just reporting start and stop times, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. The work involved in programming and monitoring will not always be continuous, so one overall unit of service time can simplify coding.

Example: Your neurologist needs to reprogram a vagus nerve stimulator (cranial nerve) for a Parkinson's patient. The device affects pulse amplitude, pulse duration, pulse frequency, dyskinesia (781.3, Lack of coordination), dystonia (333.6, Idiopathic torsion dystonia), and tremor (781.0, Abnormal involuntary movements). The documentation shows that the neurologist spent 58 minutes reprogramming the neurostimulator and 30 minutes monitoring the patient's response to the new settings.

You would report one unit each of 95974 and 95975. Reason: The reprogramming of a device with four features (including more than one clinical feature) qualifies as complex, meaning that your reporting will be time-based. Because the neurologist clearly documents 88 minutes of total work, you can claim 95974 for the first hour and add on 95975 for the additional 28 minutes.

Stop the clock: Time is not a factor in the programming and analysis of a simple neurostimulator (95971) or in the analysis of a previously implanted simple or complex neurostimulator without reprogramming (95970).

Delve Into Payer Preferences

You should analyze your payers- policies to discover if they impose any frequency guidelines on neurostimulator programming or if they bundle analysis and programming into the surgical procedure.

This is complicated by the fact that Medicare national coverage determinations (such as 160.18 for vagus nerve stimulation) have left many of these guidelines up to individual carriers. -And not only that, you could have direction from Medicare that could be different from your private-payer preferences,- Mac says.

For example, a common local Medicare carrier policy states that programming codes 95971-95975 will be reimbursed as medical necessity justifies. However, Cahaba GBA further specifies, -CPT codes 95970 or 95971 will be reimbursed at a frequency of no more than once every 30 days.-

Beware of bundles: CPT states that the codes for surgical implantation of a pulse generator do not include evaluation, testing, programming or reprogramming. But the National Correct Coding Initiative (NCCI) and many Medicare LCDs can hamper your reimbursement efforts by bundling analysis and/or programming codes into pulse generator insertion.

For example, if a neurosurgeon inserted a spinal neurostimulator and reported 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling), you would be caught in a bundle if you tried to bill 95974 for programming of the device.

Best bet: Because of the variability of coverage limitations and bundling issues, you will want to contact your individual carrier for its guidelines prior to billing.