Neurosurgery Coding Alert

Not All Payers Allow Separate Reimbursement

CPT states that the codes for surgical implantation of a pulse generator do not include evaluation, testing, programming or reprogramming. WPS Medicare Part B for Illinois and Michigan (policy NEURO-004), for example, states, "General practice is for the neurosurgeon alone to bill for the surgery A separate procedure code for electronic analysis services (CPT 95974 or 95975) may be appropriate if the neurologist/neurophysiology team adjusts and initiates initial stimulus levels in the operating room." Not all payers follow CPT guidelines, however. Blue Cross/Blue Shield North Dakota's local medical review policy (LMRP) states, "Adjustments during the initial 90 days after implantation are considered to be part of the global period."
 
And the National Correct Coding Initiative (NCCI) and many Medicare LMRPs bundle simple analysis/programming (95971) to pulse generator placement but will allow you to bill separately for complex pulse generator programming (95972-95973). Because of the variability of coverage limitations and bundling issues, contact your individual carrier for its guidelines prior to billing.
 
According to the typical local Medicare carrier policy, if you can demonstrate medical necessity, programming codes (95971-95975) "will be reimbursed at a frequency of every 30 days." Blue Cross Blue Shield North Dakota (BCBSND) #99.07 further specifies, however, that "billing any of the 9597x procedure code series after the first analysis/programming session will require submission of supporting documentation for the necessity of the service." This would include evidence of worsening symptoms (for example, rigidity) or demonstrated adverse effects arising from the current neurostimulator settings.
 
Applicable ICD-9 codes and coverage limitations vary by payer and condition, but you will generally report the same diagnosis that provided justification for the pulse generator's implantation, says Frank Falco, MD, an AMA CPT editorial board member representing the American Academy of Physical Medicine and Rehabilitation.
 
Documentation must clearly support the code selection by listing the stimulus parameters addressed and time involved. When documenting fewer than three stimulus parameters, you must report the "simple" codes no matter how much time the neurologist needs to complete the service.
 
The most efficient way to document neurostimulator analysis/reprogramming is to use a chart to track the parameters adjusted, electrode array, results and time for each trial, with a space to tally the total time, Falco says. In this way, the insurer has all the information needed to verify the time involved and the legitimacy of the claim (see below for sample documentation sheet).