Neurology & Pain Management Coding Alert

Question:  We’re billing out the following codes for a Medicare patient’s stimulator trial:  

• 63650 
  
• 63650-51 
  
• 77003 
  
• J0690 
  
• S0020.
  

We’ve been getting paid when filing this way, but now the stimulator sales rep wants us to use modifier 50 instead of modifier 51. Should we change to 50, or stick with what we’ve filed before?

Rhode Island Subscriber

Answer:  Modifier 50 (Bilateral procedure) designates a bilateral procedure, which wouldn’t apply in this situation. In addition, the Medicare Physician Fee Schedule lists a “0” bilateral payment indicator for code 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) so the 150 percent payment adjustment for bilateral procedure does not apply. If you report the procedure with modifier 50 or with modifiers LT (Left side) and RT (Right side), Medicare will base the payment for the two sides on the lower of (a) the total actual charge for both sides or (b) 100 percent of the fee schedule amount for a single code. For 2014, the national Medicare non-facility payment for 63650 based on the conversion factor of 35.8228 is $1,349.44. Other commercial payers may in fact deny the 63650 code when reported as bilateral with modifier -50 rather than process the incorrect coding as Medicare does. 

Modifier 51 (Multiple procedures) is a better choice and the correct one to file if it fits the payer’s guidelines. Focus more on the payer’s written requirements than that of the medical device rep. 

Also notice that 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid]) is a Column 2 Code paired with 63650, according to the latest Correct Coding Initiative edits. (You can unbundle the edit and report both codes by appending a modifier to 77003, provided you have sufficient documentation that the fluoroscopic guidance was used with a different procedure from the epidural neurostimulator lead implantation.) Information in two issues of CPT® Assistant (August 2010 and December 2010) also states that fluoroscopic guidance is considered to be an inherent part of the procedure reported with 63650 so should not be coded separately. 

The remaining codes you’ve listed are correct: 

• 63650 – Percutaneous implantation of neurostimulator electrode array, epidural 
  
• J0690 – Injection, cefazolin sodium, 500 mg 
  
• S0020 – Injection, bupivicaine hydrochloride, 30 ml. 
  

Note, however, that Medicare and other federal payers do not recognize S codes. Private payers might accept S codes on their claims.