Neurosurgery Coding Alert

Attention to trials and reprogramming can help to strengthen your claims

Your chances of successfully reporting your neurosurgeon's spinal neurostimulator implant services will improve dramatically if you can capture all the steps in the operative note. Correctly assigning codes depends on identifying a typical sequence, which includes placing a trial electrode, removing it, placing a long-term electrode, implanting a pulse generator, and lastly programming it at regular intervals according to the clinical response.

Code for Each Trial Array

Most patients will be subjected to a trial before they are given permanent electrodes. "Trial placement of electrodes is done to make sure a patient can tolerate it before a permanent one is placed," says Teresa Thomas, BBA, RHIT, CPC, practice manager II, St. John's Clinic -- Neurosurgery, Springfield, Missouri. The trial placement helps to test and confirm the relief from pain. "The trial helps to determine if spinal cord stimulation provides relief to the patient prior to performing a more invasive procedure," explains Gwendolyn M. Flaherty, CPC, NeuroScience Associates, Idaho. "The trial helps to assure that the neurostimulator will be beneficial to the patient," says Marilyn Glidden, CPC, NeuroScience and Spine Associates, Naples, Florida. You should be specific in the number of electrode arrays that were placed and code for each of them.

Example: If, in bilateral leg pain, the surgeon places two electrode arrays in the epidural space for trial neurostimulation and the patient returns a week later with positive results, you code 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) for the trial electrode placement. You may further read that the surgeon disconnected the external neurostimulator and removed the trial electrode at the second visit. You report code 63661(Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed). The surgeon may like to see the patient for placement of a new electrode array and implantation of the long-term generator. In this case, you would code 63650 for the new electrode array placement and 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling) for the new pulse generator implanted. If instead of electrode arrays, the neurosurgeon does a laminectomy and implants plate or paddle electrode(s) for stimulation, you report 63655 (Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural) instead of 63650.

Remember: You append modifier -59 (Distinct procedural service......) to the second (and each succeeding) unit of 63650 or 63655 to imply that the surgeon placed the additional electrode arrays at different anatomical sites. Additionally, you would append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period.....) to 63650/63655 and 63685 in the example above to imply that the services rendered at the final visit were anticipated and planned by the surgeon. "Modifier 58 can be used if you are doing electrode placement one day and connecting the generator later," explains Thomas.

You will need to be careful that the global period is different for the handling of electrodes and the paddles. "Codes have 10 or 90 global days," says Flaherty. Codes 63661 and 63663 have a 10-day global period and codes 63662 (Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed) and 63664 (Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via  laminotomy or laminectomy, including fluoroscopy, when performed) have a 90-day global period because they require laminectomy or laminotomy.

Caution: The epidural electrode arrays may be placed under fluoroscopic guidance but you do not report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction) in addition to 63650 as the Correct Coding Initiative (CCI) bundles the two. "Fluoroscopy is bundled into 63650," affirms Flaherty. "CCI edits tell you not to bill separately," confirms Glidden.

Pay Attention To Reprogramming Changes

The patient may see the surgeon every month for reprogramming of the simulator. You should report codes depending upon whether or not any changes were made in the pulse generator. Neurostimulators may be simple or complex depending upon whether these are capable of affecting three or more of the parameters like pulse amplitude, pulse duration, train spacing, number of programs, number of channels, alternating electrode polarities, output modulation, cycling, impedance and patient compliance measurements. CPT® codes apply to both simple and complex neurostimulators.

Example: You would report code 95972 (Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour) when the surgeon makes changes in the complex neurostimulator and the effort lasts up to an hour. In an extended programming, you report code +95973(Electronic analysis of implanted neurostimulator pulse generator system [eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements]; complex spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour [List separately in addition to code for primary procedure]) for every additional 30 minutes spent on the job.

In a rare instance, if the surgeon reprograms a simple stimulator, you would report code 95971 (... simple spinal cord, or peripheral [i.e., peripheral nerve, autonomic nerve, neuromuscular] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming). If, however, the surgeon makes no programming changes, you would report 95970 (Electronic analysis of implanted neurostimulator pulse generator system [eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements]; simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming).

Tip: You select a programming code for a pulse generator depending upon the number of parameters the device is capable of affecting and not on the basis of what parameters were changed or adjusted by the surgeon. For any revisions or removal of the electrodes in a subsequent visit, you would report 63661 for percutaneously placed electrodes. You report 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver) when the surgeon revises or removes a previously implanted pulse generator. "You do not report for programming if there is a representative doing it rather than the surgeon," says Flaherty.

Remember: If you read that the surgeon removed the pulse generator for a failed battery and replaces it with a new generator, you select code 63685. "Append modifier -78 only if the replacement or revision occurs in the global period of the initial procedure," says Dr. Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.