Neurosurgery Coding Alert

A well documented pre-SCS trail, allowed ICD-9 code, and secured ABN can be the birds in your hand that you need to gain neurostimulation payment from the insurer -- or your customer.

Neurostimulation is a fairly common method of helping patients cope with certain neurological disorders or types of chronic pain, but increased use doesn't guarantee reimbursement. Follow our three steps to verify your carrier's stance on neurostimulation up front and increase your chances of successful filing and reimbursement.

On your quest to secure greenbacks from insurers for neurostimulation, make sure charts show the path that got the patient to this treatment.

"Having documentation that your physician tried other treatments that were ineffective helps show that neurostimulation might be what the patient needs to relieve his or her pain," explains Darlene Ogbuagu, CPC, ACS-AN, a billing and referral supervisor at Northwestern Medical Faculty Foundation, Inc., in Chicago. Expect the chart to illustrate that the patient reached this treatment as a last step.

"Spinal cord stimulation (or SCS) is a treatment typically recommended when all other means of treating or eliminating pain have either been ineffective or have side effects that interfere with the patient's quality of life," Ogbuagu adds.

What kind of conditions can you expect to see in the patient's initial encounters? Many patients who have neurostimulation treatments suffer from a variety of chronic pain conditions. These can include chronic radiculopathy (sciatica), failed back syndrome, neuropathy, reflex sympathetic dystrophy, post herpatic neuralgia, or vascular insufficiency. Neurostimulation becomes an option for these patients after they've already tried other treatments or have undergone special tests.

Criteria that help determine whether neurostimulation is a viable option for the patient include:

• More conservative therapies (such as over-the-counter or prescription medications, trigger point or facet injections, physical therapy, or corrective surgery) have failed to adequately relieve the pain.

• Clinical history or neurophysiological studies (such as a nerve conduction study) localize the pain's origin and the physician diagnoses the cause of pain.

• Tests don't indicate the need for further traditional surgery such as decompression to treat the patient's pain.

• No medical issues exist that might present problems if your surgeon places a neurostimulator (such as susceptibility to infection).

• The patient successfully passes physical and psychological evaluations to determine whether an undiagnosed problem (such as depression or anxiety disorder) may have an adverse effect on the outcome of the neurostimulator treatment.

• The screening test and neurostimulator trial are considered successful.

Always check the carrier's SCS policy for neurostimulation. Although the past few years have seen a rise in neurostimulation treatments, some carriers still consider the procedure to be investigational -- and hence uncovered -- for some diagnoses.

Some carriers have short lists of conditions that justify neurostimulator treatments. For example, Blue Cross/Blue Shield of Tennessee lists only three groups of conditions that support medical necessity including:

• Radiculopathies (diseases involving the nerve roots such as failed back syndrome, arachnoiditis, and epidural fibrosis). This category includes many diagnoses such as 729.2 (Neuralgia, neuritis, and radiculitis, unspecified), 322.9 (Meningitis, unspecified), and others.

• Reflex sympathetic dystrophy (also known as complex regional pain syndrome type 1). Choose the appropriate code from 337.2x.

• Intractable pain from severe peripheral vascular disease (PVD). Although carriers recognize "intractable pain" as an acceptable diagnosis, ICD-9 does not include a specific code for it.

Filing tip: When reporting these cases involving intractable pain, list the patient's type of pain first (such as 355.71, Causalgia of lower limb), followed by the PVD as a secondary condition.

Even if the carrier's policy includes your patient's condition on its list of approved diagnoses, experts still recommend obtaining certification before scheduling the procedure. They also recommend that you ask the patient to sign an advance beneficiary notice (ABN), especially if the carrier classifies the stimulator placement as an investigational procedure.

"You use an ABN when the carrier does not cover the treatment, thereby informing the patient that he or she might be responsible for the cost," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Check your carrier's stance, because it might consider neurostimulator use to be investigational even for common conditions such as:

• Intractable angina -- 413.9 (Other and unspecified angina pectoris)

• Plexus lesions caused by trauma or malignancy -- 353.x (Nerve root and plexus disorders), 720.x (Ankylosing spondylitis and other inflammatory spondylopathies), 721.x (Spondylosis and allied disorders), 722.x (Intervertebral disc disorders), 723.x (Other disorders of cervical region), or 724.x (Other and unspecified disorders of back)

• Multiple sclerosis - 340

• Neuropathy due to injuries, surgery, entrapment, or scars -- diagnoses such as 355.9 (Mononeuritis of unspecified site) or 354.4 (Causalgia of upper limb)

• Postamputation pain -- 353.6 (Phantom limb [syndrome])

• Postherpetic neuralgia -- 053.12 (Postherpetic trigeminal neuralgia), 053.13 (Postherpetic polyneuropathy), or 053.19 (Herpes zoster; with other nervous system complications; other).