Neurosurgery Coding Alert

When billing for implanting deep brain stimulators to treat Parkinsons disease, neurosurgeons often have difficulty getting fully reimbursed for the procedure because insurance carriers may doubt its medical necessity. But by sending precertification letters to the carriers explaining the patients condition and failure to respond to other types of treatment, surgeons can ensure they are receiving proper payment for their services.

The following case study and coding procedures were provided by Shirley Triche, RN, nurse to Mahlon R. DeLong, MD, chairman of the neurology department at the Emory Clinic in Atlanta.

Case Description: A 76-year-old male diagnosed with Parkinsons disease five years ago has been using medications to control his symptoms. The patient had been responding well but recently the medications have not been performing as well. The patient has agreed to have a deep brain stimulator implanted to control the symptoms of the disease as medication is no longer an effective treatment.

Procedure: An MRI is taken to determine the general area of the brain requiring stimulation. Microelectrode guided physiological localization is employed to isolate the target region in the brain from the initial coordinates provided by the MRI. The neurosurgeon performs individual recordings in two to three planes of the brain structure. Based on these recordings, the neurosurgeon determines where the deep brain stimulator lead should be implanted.

The patient is brought to the operating room and anesthetized. A hole is drilled through the patients skull to allow access to the target area and the deep brain stimulator lead is placed within the necessary brain structure. Prior to complete deep brain stimulator implantation, the neurosurgeon tests the lead to determine if the electrical stimulation provided improves the patients symptoms. This is done initially at the lowest possible voltage to lower the risk of side effects. The neurosurgeon slowly increases the stimulus until optimal stimulation has been achieved. Once the appropriate level of electrical stimulation has been determined, the lead is implanted using a burr hole ring and a cap securing the lead in place.

The neurosurgeon tunnels extension tubing down behind the ear along the sternocleidomastoid muscle to a battery pack implanted just below the clavicle. Usually, the patients stimulator is not programmed for about 30 days because the instrumentation process and placing the leads often temporarily alleviates the patients symptoms. Retesting of the stimulator and any necessary programming or adjustments are therefore not possible until the symptoms are again present.

After surgery, the patients hospital stay is typically two-and-a-half days, provided there are no complications. The programming is performed during a later outpatient visit.

Coding Notebook

To ensure rightful reimbursement, Triche recommends sending precertification letters to Medicare and private insurance companies, explaining the [...]