Neurosurgery Coding Alert

New CMS guidelines allow for broader use of deep brain stimulation (DBS) for treatment of essential tremor (ET) and Parkinsons disease. When applying DBS, surgeons must be careful to report all portions of the service (including incision, placement and, in some cases, programming; see Dont Forget to Charge for Programming ) while supplying an appropriate diagnosis and meeting other submission requirements.

Document the Appropriate Conditions

DBS refers to high-frequency electrical stimulation of anatomic regions deep within the brain using surgically implanted electrodes. The surgeon may place the electrodes on one (unilateral) or both (bilateral) sides of the brain at one of three locations: the thalamic ventralis intermedius nucleus (VIM), subthalamic nucleus (STN) and globus pallidus interna (GPi).
 
Beginning April 1, CMS program memorandum, transmittal AB-03-023 (change request 2553), instructs carriers to pay for (previously uncovered) unilateral or bilateral VIM DBS for the treatment of ET and/or Parkinsonian tremor and unilateral or bilateral STN or GPi DBS for the treatment of Parkinsons disease. The memo specifies that all DBS units must meet with U.S. Food and Drug Administration approval and outlines the following conditions for coverage:
 
For thalamic VIM DBS:
 
The patient must have a diagnosis of essential tremor based on postural or kinetic tremors of hand(s) without other neurologic signs, or a diagnosis of idiopathic Parkinsons disease (exhibiting at least two cardinal features of Parkinsons, such as tremor, rigidity or bradykinesia) of a tremor-dominant form.
 
Marked disabling tremor of at least level three or four on the Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or equivalent scale) in the extremity intended for treatment, causing  significant limitation in daily activities despite optimal medical therapy.

 For STN or GPi DBS:
 
A diagnosis of Parkinsons disease based on the presence of at least two cardinal features of Parkinsons (tremor, rigidity or bradykinesia).
 
Presence of advanced idiopathic Parkinsons as determined by the use of Hoehn and Yahr stage or Unified Parkinsons Disease Rating Scale (UPDRS) part III motor subscale.
 
The patient is L-dopa responsive with clearly defined on periods.
 
The patient must exhibit persistent disabling Parkinsons symptoms or drug side effects (for example, dyskinesias, motor fluctuations or disabling off periods) despite optimal medical therapy.
 
In all cases, the patient must be willing and able to cooperate during a conscious operative procedure, as well as during postsurgical evaluations, adjustments of medications, and stimulator settings.
 
Documenting that you have met these requirements is essential, says Jennifer Schmutz, CPC, of Neurosurgical Association in Salt Lake City. Regarding DBS, the hardest part has been getting the insurances to authorize the procedure, she says. Once that has been done, we havent had problems receiving payment. But to get an authorization, I have to prove that medications, therapy and other options have been tried.

Watch for Caveats

Memo AB-03-023 further specifies conditions for which Medicare will not cover DBS, including:
 
nonidiopathic Parkinsons disease or Parkinsons Plus syndromes
 
cognitive impairment, dementia or depression that would be worsened by or would interfere with the patients ability to benefit from DBS
 
current psychosis, alcohol abuse or other drug abuse
 
structural lesions such as basal ganglionic stroke, tumor or vascular malformation as etiology of the movement disorder
 
previous movement-disorder surgery within the affected basal ganglion
 
significant medical, surgical, neurologic or orthopedic comorbidities contraindicating DBS surgery or stimulation.

Report All Portions of Implantation

Implantation of the DBS unit is a multistep procedure, says Richard D. Bucholz, MD, FACS, professor and associate director of the division of neurosurgery at St. Louis University in Missouri. The unit is composed of a generator and one or more electrodes, which the surgeon places separately during the same operative session.
Mapping to identify vital structures will occur prior to implantation, and you may report this service using 95961 (Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance) and +95962 ( each additional hour of physician attendance [list separately in addition to code for primary procedure]), as necessary. Because these are time-based codes, be sure to document carefully the time the physician dedicates to the mapping. And because the physician provides interpretation only, you must append modifier -26 (Professional component) to any/all units of 95961 and 95962.
 
At the time of surgery, the neurosurgeon uses brain-imaging equipment (magnetic resonance imaging [MRI] and/or computed tomography [CT]) for stereotactic localization and targeting of the surgical site(s), Bucholz says. According to the National Correct Coding Initiative, the surgical approach as described by 61862 (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]) includes placement of the stereotactic frame, with determination of placement and/or alignment by CT or MRI.
 
Report placement of the pulse generator and electrode(s) using 61885 (Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array) or 61886 (... with connection to two or more electrode arrays), as appropriate. Both 61885 and 61886 involve internalization of the tail of the electrode array and placement and connection of a subcutaneous neurostimulator generator for long-term brain stimulation, according to CPT Assistant (November 1999). Code 61886 differs in that the same insertion procedure is repeated for the electrode array on the other side, including tunneling of the tail of this electrode to the second limb of the bifurcated extension wire.
 
And you may recover the cost of the neurostimulator equipment (only if supplied by the surgeon) using E0752 (Implantable neurostimulator electrodes, each) and E0756 (Implantable neurostimulator pulse generator). Use E0752 to report each electrode, and use the units box of the claim form to indicate the total number of electrodes placed. Never bill multiple units of E0756, because only a single generator is necessary.

Access Special Codes for Revisions

Bucholz reminds that CPT includes specific codes to report removal or revision of the DBS unit: 61880 (Revision or removal of intracranial neurostimulator electrodes) and 61888 (Revision or removal of cranial neurostimulator pulse generator or receiver). Code 61880 includes repositioning of the electrode to enhance patient response. If the revision/removal occurs during the global period of the initial surgery, append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the appropriate code.