Neurology & Pain Management Coding Alert
Here's How
If you've been providing electrical stimulation for patients with spinal cord injuries, here's good news. On July 22, CMS announced that it would expand coverage of neuromuscular electrical stimulation (NMES) "to assist people with spinal cord injuries in walking." This can mean increased billing opportunities and reimbursement for your practice, but only if you report the appropriate code and provide the necessary documentation. Report Attended Study Although electrical spinal cord treatment is "neuromuscular electrical stimulation," you should not report it using 64565 (Percutaneous implantation of neurostimulator electrodes; neuromuscular). Rather, the neurologist must provide - and you must report - an attended electrical stimulation application. You should report 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 an electrical stimulation code such as 97014 (... electrical stimulation [unattended]) because it refers to a therapy modality that does not require the presence of a clinician, says John Whitemore, PT, a physical therapist in Duluth, Ga. Observe Coverage Limitations Documentation plays an important role in guaranteeing coverage for NMES. For example, not all spinal cord-injured patients can use NMES devices for walking, and therefore, CMS has declared that it will only cover NMES for patients with: Additionally, 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, and must "demonstrate brisk muscle contraction in response to NMES and have 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. Note: For complete information on coverage of NMES, go to www.cms.hhs.gov/coverage/8b3-mm.asp. Differentiate NMES from TENS When neurologists use a form-fitting garment that delivers NMES electricity directly to the patient, report this service with E0731 (Form-fitting conductive garment for delivery of TENS or NMES [with conductive fibers separated from the patient's skin by layers of fabric]). Because the descriptor for E0731 includes the word "TENS," some physicians and coders may believe that TENS and NMES are synonymous. Rather, TENS refers to transcutaneous neurostimulators, which the neurologist may use to anesthetize nerves to control or block pain. The appropriate code for TENS is 64550 (Application of surface [transcutaneous] neurostimulator). Some neurology practices skim the descriptors listed under TENS in CPT and see "neuromuscular" listed, "and they'll accidentally choose 64565 for NMES," Humphrey says. "But 64565 is for implantation of electrodes, whereas NMES is a therapy modality."
"The biggest difference between 97032 and 97014 is that the therapist or physician must stay with the patient during the attended code [97032]," Whitemore says. "Another big difference is that 97014 is not a time-based code, so you should only bill it once per session. Even if the patient receives unattended electrical stimulation for 45 minutes, you would bill only one unit of 97014, whereas 45 minutes of 97032 would be billed as three units."
Note that "each 15 minutes" as referenced in the supervised modality code descriptors (such as 97032) "Describe the total time, i.e., preservice, intraservice, and postservice time spent in performing the modality," according to the December 1998 CPT Assistant. Therefore, if the neurologist examined a patient before performing the electrical stimulation to determine whether his condition changed since his last visit, that time would be counted as "preservice" minutes and could be included in the total time spent with the patient and billed toward 97032.
"TENS coding is subject to even further confusion, because most carriers' LMRPs advise billing 97032 one or two times when training the patient on how to use TENS at home," says Melissa Humphrey, coding and billing coordinator at Warren Rehabilitation in Orlando, Fla. "Remember that 97032 is only used when training a patient on TENS." Bill actual application of TENS using 64550, she says.
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