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 medical necessity for the deep brain stimulator implantation. She suggests making it clear in the letter that the patient is medically refractory (i.e., medications no longer improve his or her symptoms) or that the patient is so prone to side effects from medications that his or her quality of life is being impaired rather than improved and so, at this time, surgical options are appropriate.

The Emory Clinic does not have to acquire precertification for their Medicare patients because the clinic has secured a blanket approval from the Medicare organization of the southeast region to do this procedure. Such approval may be gained on a regional level. For example, the Emory Clinic treats patients from Georgia, Tennessee, South Carolina, Alabama and Florida. Triche says the cost of the procedure runs approximately $45,000, including the expense of the deep brain stimulator, billed as a medical prosthesis at approximately $14,000.

Erwin B. Montgomery Jr., MD, director of the movement disorders program from the Cleveland Clinic in Cleveland, which has nearly 30 neurosurgeons on staff, provides the following preoperative information, procedural coding and postoperative information.

In the preoperative evaluation, the Unified Parkinson Disease Rating Scales/Quality of Life Assessment is administered by nursing personnel under the direct supervision of a neurosurgeon or neurologist. This neuropsychological assessment is performed to judge if a patient is an acceptable candidate for surgery and to establish the preoperative baseline for subsequent evaluations.

The operative procedures and costs begin with the MRI of the head (70551-26) and include the neurosurgeons following surgical fees: twist drill, burr hole, craniotomy, or craniectomy for stereotactic implantation of one neurostimulator array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray) (61862), stereotactic computer assisted volumetric (navigational) procedure, intracranial, extracranial or spinal (61795, an add-on code), incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array (61885).

Intraoperative monitoring is performed by the neurologist (both professional and technical fees should be assessed only if the neurologist is using his or her own equipment; otherwise, the -26 modifier should be appended to indicate the professional component only): Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on the brain surface, or of depth electrodes to provoke seizures or identify vital brain structures, initial hour of physicians attendance, 95961; each additional hour of physician attendance 95962). Included in this portion of the billing is monitoring microneuronal recording and microstimulation for precise target site identification. Complex brain, spinal cord or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming (first hour: 95972; and subsequent 30 minutes: 95973). Note that more than three parameters are monitored and/or adjusted and more than one clinical response is monitored.

The patient is evaluated by the neurosurgeon or neurologist one day after the procedure. The evaluation takes approximately 30 minutes and is billed with an evaluation and management (E/M) code that best represents the documented service, typically 99213-99214 (office or other outpatient visit for the evaluation and management of an established patient). At the one month evaluation, the stimulator may be adjusted by nursing personnel under the direct supervision of a neurologist. (Electronic analysis of implanted neurostimulator pulse generator system [may include rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements] complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing: 95974 for the first hour and 95975 for each subsequent 30 minutes). Note once again that more than three parameters were monitored and adjusted and more than one clinical response was monitored.

If the neurosurgeon needs to reposition the leads in a separate operative session, code 61880 (revision or removal of intracranial neurostimulator electrodes) appended with modifier -78 (return to the operating room for a related procedure during the postoperative period) if the adjustment is performed within the global period.