Neurosurgery Coding Alert

Check off the relevant info of temporary or permanent, open or closed, and reprogramming change and device type to make your coding for spinal cord stimulators (SCS) and follow-up a snap.

Last month you successfully navigated your way through the documentation, medical necessity, and diagnosis requirements for a patient who's scheduled for a neurostimulator implant procedure. But the treatment doesn't stop there, so close out your claim with the best coding for surgery and follow-up care.

As a neurosurgical coder, you'll probably see spinal cord stimulation (SCS) for patients who have painful limb conditions, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. To determine the applicable implantation code, ask these questions:

1. Is this SCS placement a trial or permanent?

2. If the equipment placement is temporary, did your surgeon use an open approach? You'll use two codes most often for SCS placement, with a third option to sometimes consider:

• 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) "is often performed in a trial to determine whether an implant will successfully manage the patient's painful condition," Przybylski says.

• Use 63655 (Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural) for open placement by laminectomy. This "allows for safe positioning of a flat paddle electrode in the epidural space if a larger area of coverage is required or to minimize the risk of stimulator array migration," Przybylski says.

"However, a long-term implanted array must be connected to an implanted pulse generator."

• If your surgeon permanently implants a pulse generator (which you would report in addition to the other implantation code), assign 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling).

Don't forget: CPT's codes for spinal neurostimulators apply to both simple and complex equipment. The system includes an implanted neurostimulator, external controller, extension, and collection of contacts. Multiple contacts or electrodes provide stimulation to the epidural space.

Warning: Double check that the physician implants a dorsal column, permanently implanted stimulator before coding the procedure. There are other types of stimulation treatments, so be sure you're not coding for one of the other therapies by mistake.

"Make sure your physician's documentation is as specific as possible, especially when billing for the leads," says Dawn Shanahan, CPC, supervisor of coding for Florida Gulf to Bay Anesthesiology Associates in Tampa. "How many leads, and how many contacts per lead? You don't want to leave money on the table."

Real world example: In Florida, Medicare allows $418.98 per electrode for placement in an office setting. If the lead has an 8-electrode array, your reimbursement would be $3,351.84; you'd be reimbursed $6,703.68 for a lead using a 16-electrode array. "If you don't know which type of electrode array (8 or 16) or how many lead arrays were actually placed, then how can you properly bill?" Shanahan points out.

Medicare might ask for a copy of the leads invoice and clarification of how many leads your physician placed, Shanahan says. "If the operative notes aren't clear, you could get a denial or reduced payment, which could cost you money since you have to pay for the equipment."

When SCS patients return to your office monthly for pulse generator reprogramming, code based on the type of device and whether the neurosurgeon makes any changes.

Status quo: If your surgeon doesn't make any programming changes, report 95970 (Electronic analysis of implanted neurostimulator pulse generator system [e.g., 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 [i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular] neurostimulator pulse generator/transmitter, without reprogramming).

Simple reprogramming: If your physician reprograms a simple SCS, submit 95971 (... simple spinal cord, or peripheral [i.e., peripheral nerve, autonomic nerve, neuromuscular] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming).

A simple neurostimulator is capable of affecting three or fewer of the following parameters: pulse amplitude, pulse duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time, and more than one clinical feature.

Complex changes: Codes 95972 (... complex spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour) and +95973 (... complex spinal cord, or peripheral [except cranial nerve]  neurostimulator pulse generator/transmitter, with introperative or subsequent programming, each additional 30 minutes after first hour [List separately in addition to code for primary procedure]) work hand-in-hand when your physician makes changes to a complex spinal cord stimulator (one that is capable of affecting more than three of the parameters mentioned above). Start with 95972, then add +95973 as needed.

Watch global reporting: Spinal cord stimulation procedures carry a 90-day global period. You can still report the patient's follow-up reprogramming during that timeframe, however, by adding modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the procedure code. Lower your chances of carrier questions by ensuring you document every step of the process from medical necessity and coverage verification to the actual procedure and subsequent care.