Neurosurgery Coding Alert

Implanting spinal neurostimulators involves several distinct steps, each of which offers a variety of coding opportunities. In part one of this two-part series, our experts lead you through the initial stage of the process so that you won't miss any of the reimbursement your surgeon deserves.

Candidates for spinal neurostimulation must undergo a trial to prove treatment efficacy. You will select from two codes to describe the surgeon's work during this period.

"Neurostimulators are often a -last resort- for patients with chronic, intractable pain," explains Mark Telles, senior manager of therapy access at Medtronic Neuromodulation. "Only if the patient shows benefits during a trial -- a good outcome is defined as pain relief of 50 percent or better -- will the surgeon move forward with a long-term implant."

Before you file: Check with your payer or Medicare carrier for a complete list of preconditions and allowable diagnoses for spinal cord stimulation coverage.

The trial begins with placement of one or more catheter electrode arrays, or plate/paddle electrodes, at precise locations along the epidural space around the spinal cord. The electrodes allow for direct stimulation of the dorsal columns (posterior spinal cord) to mask the patient's pain.

A catheter electrode consists of a wire "about the width of angel hair pasta," Telles explains. The physician threads the wire through a hollow needle inserted in the epidural space, using fluoroscopic guidance to ensure proper placement. The locus of the patient's pain determines the number and precise placement of electrode array(s).

For this procedure, report one unit of 63650 (Percutaneous implantation of neuro-stimulator electrode array, epidural) for each electrode array that the surgeon inserts.

Tip: The national Correct Coding Initiative bundles fluoroscopic guidance into epidural electrode array placement. Therefore, you would not report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction), when performed, in addition to 63650.

Example: If the surgeon positions two electrode arrays in the epidural space for treatment of bilateral leg pain, you would report two units of 63650. You should append modifier 59 (Distinct procedural service) to the second unit of 63650 (and all subsequent units) to alert the payer that the physician placed the additional electrodes at different anatomical locations.

Rather than an epidural electrode array, the surgeon may instead insert a plate or paddle electrode, via laminectomy, to provide stimulation. To describe such placement of a plate or paddle electrode, you would report 63655 (Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural).

"This is a more involved, invasive procedure," Telles says. "Often, candidates for this procedure will have extensive scarring from previous surgery that prevents effective placement using a catheter electrode array."

Here again, the surgeon may position more than a single plate or paddle, when required. You would report one unit of 63655 for each plate/paddle the surgeon inserts via laminectomy, appending modifier 59 to the second and subsequent units to indicate separate locations.

Finally, you may claim the surgeon's effort to program the temporary, external generator used to power and control the implanted catheter array or plate/paddle electrode(s).

"The external battery source looks a bit like a garage door opener," Telles explains. "Responding to patient feedback, the surgeon will manipulate various control settings, such as pulse width, frequency and strength, to find the correct -recipe- and stimulus location to alleviate the patient's pain."

CPT allows you to report 95972 (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]; complex spinal cord or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour) for "intraoperative (at initial insertion/revision) or subsequent electronic analysis" of a complex neurostimulator, in addition to either 63650 or 63655 for placement of the epidural or plate/paddle electrode(s).

CPT also provides an add-on code, +95973 (-complex spinal cord or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour), to describe additional programming time beyond the first hour. However, you are not likely to access this code.

"Programming rarely, if ever, takes longer than an hour," Telles notes.

Don't forget: If you do report 95973 in addition to 95972 for extended programming, be sure that the available documentation provides details as to why the surgeon required the additional time, as well as a precise record of the actual time spent.

You should only apply 95972 (and 95973, if necessary) for programming of a complex neurostimulator.

Important distinction: "The stimulation programming codes are based on what the system is capable of affecting -- not on what parameters are being used for programming at any given programming session," says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, with MJH Consulting in Denver.

Rule of thumb: In almost all cases you encounter today, you can expect that stimulators will have complex capabilities, Telles says. Simple stimulators represent an older technology that is generally not being sold any longer, he adds.

Nevertheless, be careful that documentation justifies reporting the "complex" programming code. If the pulse generator does not meet the CPT definition of complex, you should skip 95972/95973 in favor of 95971 (-simple spinal cord or peripheral [i.e. peripheral nerve, autonomic nerve, neuromuscular] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming).

Additionally, you may not report programming codes for your surgeon if a representative of the device manufacturer provides the actual programming service. This is a common occurrence, but needn't be a problem if you remember that you are coding for the physician-s effort and expense. If the surgeon or an appropriate member of his staff does not provide and document the actual service, you should not bill for it.

Next month: Look for instruction on coding from the end of the trial period to implanting the long-term neurostimulator.