Neurology & Pain Management Coding Alert

Question: Our neurologist scheduled a patient to implant a spinal cord neurostimulator. He attempted to implant one lead, but could not maneuver it into the space. He attempted a second/different lead with success. We were still charged for the first lead that could not be implanted. Can we bill for it with 63650 and a modifier to show that placement was attempted but not successful? Would reporting it with modifier 52 be appropriate?

California Subscriber

Answer: Code 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) represents placement of a percutaneous neurostimulator electrode array. Physicians often insert a temporary lead to ensure the treatment will work for the patient. Once the viability is confirmed, the physician removes the temporary lead and implants a permanent neurostimulator. The work associated with removing the temporary lead is included in the initial percutaneous placement represented by 63650 (CPT Assistant, August 2010).

It’s not uncommon for physicians to place more than one temporary lead during an encounter, either at the same spinal level (each slightly off the midline) or in different anatomic sites. Therefore, you’re allowed to report multiple instances of 63650 on the same date of service. If you do this, however, the payer will assume the physician placed the leads in multiple locations, not the same site because of needing to start the insertion fresh.

Appending modifier 52 (Reduced services) indicates that the inherent procedure represented by the code was completed, but lacked a bit of the usual included service. That might not be the best representation of the procedure since your physician wasn’t able to get the first lead into the space for placement.

The first lead’s attempted placement possibly was involved enough to bump up the work associated with the successful second placement, but not enough to stand on its own as a “reduced services” procedure. Therefore, your better option might be to report one unit of 63650 with modifier 22 (Increased procedural services). The physician’s documentation must validate the substantial additional work.  For example, modifier 22 may be supported by additional documentation indicating increased intensity, time, technical difficulty or severity of the patient’s condition.