Neurosurgery Coding Alert

If a surgeon moves forward with permanent placement of spinal neurostimulators, you will find yourself accessing many of the same codes you called upon to report the trial placement -- with a few wrinkles and additions. Read on for the rest of the story on error-free coding for spinal neurostimulators.

Last issue, we learned that most candidates for spinal neurostimulation must undergo a trial to prove treatment efficacy, and that you would report the trial placement of the stimulating electrodes using either 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) or 63655 (Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural), as appropriate.

In addition, you may report the surgeon's effort for programming the temporary, external generator used to power and control the implanted catheter array or plate/paddle electrode(s), most often using 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).

After a successful trial, you would report the surgeon's implanting of a long-term pulse generator for continued treatment. This may involve up to three steps, explains Mark Telles, senior manager of therapy access at Medtronic Neuromodulation.

1. First, the surgeon may disconnect the temporary pulse generator and remove the previously placed electrode(s), for which you should report 63660 (Revision or removal of spinal neurostimulator electrode percutaneous array[s] or plate/paddle[s]). Claim this code only once, regardless of the number of catheter arrays or plates/paddles the surgeon removes.

In addition, you should append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to show that the surgeon anticipated the procedure.

2. After a period of healing following removal of the previously placed electrodes, the surgeon will place a new catheter array(s) or plate(s)/paddle(s), as required. You will report these services using 63650 or 63655, as described previously ("One-Step-at-a-Time Ensures Successful Spinal Stimulation Claims," Neurosurgery Coding Alert, Vol. 9, No. 9, pages 65-67).

Once again, you should append modifier 58 to denote a staged service that occurs during the global period of an earlier procedure.

3. Finally, the surgeon will implant the long-term pulse generator, for which you would report 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling) with modifier 58.

"The implant occurs via a separate incision, usually either in the belly or the buttocks just below the waistline," Telles explains. "The surgeon then connects the leads to the generator by tunneling the wires under the skin."

Example: The surgeon places a catheter electrode array for trial neurostimulation. The patient returns four days later and reports positive results. The surgeon disconnects the external neurostimulator and removes the trial electrode. Two weeks later, the patient returns for placement of a new electrode array and implantation of the long-term generator. You would report:

- 63650 for the trial electrode placement

- 63660-58 for removal of the trial electrode at the second visit

- 63650-58 for placement of the long-term electrode array at the final visit

- 63685-58 for implanting the pulse generator at the final visit.

Watch for: Occasionally, the surgeon will attach the long-term pulse generator to the previously placed electrodes. In other words, he will not replace the catheter arrays or plate/paddle electrode(s) used during the trial period. When this occurs, you would report 63685 for inserting the pulse generator, in addition to initial placement of the electrodes (63650) only.

Example: The surgeon places the electrode array and tests the patient "on the table" for response to the stimulation. The patient shows benefit and the surgeon immediately implants the long-term generator, attaching it to the same leads he used for the trial.

You would report 63650 and 63685. Because the entire procedure occurs on the same date of service, you will not need modifier 58.

After the surgeon has placed the permanent pulse generator, you will have additional opportunities to bill for programming services.

Remember: Most modern neurostimulators qualify as "complex," as defined by CPT, and therefore you would report 95972 for the first hour of programming, Telles says. In the unusual event that the surgeon would require longer than an hour for programming, you may report +95973 (-complex spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative subsequent programming, each additional 30 minutes) to describe each additional 30 minutes.

In the equally unlikely event that the surgeon programs a "simple" (as defined by CPT) neurostimulator, you would 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).

Important: You should choose a programming code based on the number of parameters the pulse generator is capable of affecting, not the number of parameters the surgeon alters, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, with MJH Consulting in Denver.

Finally, you may call on 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 neurostimulator pulse generator without reprogramming) for "interrogation of the neurostimulator battery," Telles explains.

In other words, you may call on 95970 "to describe analysis of an implanted neurostimulator pulse generator without reprogramming," according to CPT Assistant (Sept. 2005).

Observe frequency limitations: The surgeon may have to adjust the neurostimulator parameters (such as pulse frequency, duration, and amplitude, among others) over time to provide the patient with maximum benefit. Although you may bill for these ongoing programming sessions, most payers will not consider programming necessary more often than once every 30 days.

If the surgeon removes or revises the neurostimulator leads at a future date, you may once again report 63660.

Should the surgeon revise or remove a previously implanted pulse generator, you should select 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver).

Watch for immediate replacement: If the surgeon removes and immediately replaces the pulse generator, however (such as for a battery change), you should report 63685 rather than 63688.

You would not need a modifier in any of these cases, unless the removal or revision occurred during the global period of a previous procedure.