Neurology & Pain Management Coding Alert

Question: I've heard recently that Medicare will accept claims for electrical stimulation for treating patients with spinal cord injuries, but my claims have been denied. Any suggestions?

New York Subscriber

Answer: You could have made one of two mistakes: not choosing the correct code or not providing documented evidence of medical necessity for the procedure.
 
Medicare will only pay for attended electrical stimulation as described by 97032 (Application of a modality to one or more areas; electrical stimulation [manual], each 15 minutes) for electrical spinal cord treatments that require "constant attendance" and, therefore, direct patient-to-provider contact, according to CPT.
 
You should not report either code 64565 (Percutaneous implantation of neurostimulator electrodes; neuromuscular) - a common mistake - or an unattended study such as 97014 (... electrical stimulation [unattended]).
 
Code 97032 is a time-based code, and you may report one unit for each 15 minutes the neurologist spends with the patient.
 
For instance, if the neurologist administers stimulation for 35 minutes in constant attendance with the patient, you would report 97032 x 2.
 
Furthermore, documentation plays an important role in guaranteeing coverage for electrical stimulation. CMS has declared that it will only cover NMES for patients with: 

 - intact lower motor units (L1 and below) 
 -  at least six months of postrecovery spinal cord injury and restorative surgery 
 -  no hip and knee degenerative disease 
 -  no history of long bone fracture secondary to osteoporosis.

And patients must demonstrate:

 - a willingness to use device long-term, must have completed regular sessions of physical therapy with the device over a period of three months 
 - brisk muscle contraction in response to NMES
 - sensory perception of electrical stimulation sufficient for muscle contraction, CMS says.

If the physician fails to include evidence in the medical record that the patient meets these qualifications, your claims will face denial.