Neurosurgery Coding Alert

Surgical insertion of spinal cord neurostimulators for pain management is a complicated related/staged surgical procedure that many insurance company payers do not understand. Consequently, reimbursement for this procedure may be decreased dramatically by carriers who bundle what should be individual codes or strike what they believe to be duplicate billing. But by learning Medicares guidelines for the procedure and educating insurance carriers about them, neurosurgeons can ensure proper reimbursement.

Rhonda Petruziello, CPC, a neurosurgery reimbursement specialist who works with the Cleveland Clinic Foundation in Cleveland, says neurosurgeons can educate their carriers about this procedure by providing them with a procedural analysis, showing them exactly what is involved.

1. Coding the Insertion of Spinal Cord Stimulators

The introduction of a spinal cord stimulator for pain reduction into a patient is a two-stage process requiring surgery to two separate and distinct areas of the body. Depending on the patients response during the first stage, both surgeries may be performed on the same day within hours of one another, or they may be performed on different days.

First, the neurosurgeon must gauge the potential effectiveness of the neural stimulation. This is the screening/trial stage. Either electrical leads will be inserted with a needle into the spine or a surgical incision will be made to allow the introduction of a plate or paddle. If the electrical leads are employed, the physician should bill 63650 (epidural percutaneous implantation of the neural stimulator electrodes). For the plate/paddle, bill 63655 (laminectomy for implantation of epidural neurostimulator electrodes, plate/paddle).

2. Billing for Test Itself

Once the method for testing has been introduced, the actual test must be performed. The temporary electrode is hooked to an external power supply, a remote control used by the patient to increase or decrease stimulation levels, and a monitoring device for analysis and programming of the system.

The patient gives verbal feedback to verify if he or she feels paresthesia or tingling over the pain area. Additionally, several other electronic tests are performed on the system. If the patient feels the tingling and the additional tests show that no programming is required, this first set of tests has been successfully executed and the neurosurgeon may bill code 95970 (electronic analysis of the implant stimulator 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 neurostimulator pulse generator without reprogramming).

If the patient does not feel the requisite tingling and tests show that reprogramming of the stimulator is required, code 95972 (complex brain or spinal cord neurostimulator pulse generator/transmitter, with intraoperative subsequent programming, first hour). If this procedure takes more than one hour, use 95973 (complex brain or spinal cord neurostimulator pulse generator/ transmitter, with intraoperative subsequent programming, each additional 30 minutes).

Note: Do not bill 95970 plus 95972 or 95973. One should be used in lieu of the other. Also, reprogramming that extends beyond 90 minutes is rare. Insurance companies will question if you bill for additional time.

The patient is now taken from the operating room and given a remote control hooked to the electrodes so he or she may increase or decrease stimulation levels to find the level that provides optimal pain relief. The patient may take several hours or days to determine the effectiveness of neural stimulation for pain reduction. A successful first stage trial is recognized if the patient receives a greater than 50 percent reduction in her pain pattern.

3. Implantation

When a successful trial is achieved, the neurosurgeon begins the second part of the procedure: the permanent implantation of the neural stimulator. The testing equipment must be removed and the neurosurgeon again has the choice of electrode leads or a paddle or plate for the permanent stimulator.

Separately, a generator, or battery, is introduced into the patients abdomen and connected to the stimulator. To bill for this portion of the procedure, code either 63650 for the electrode leads or 63655 for the plate/paddle for the placement of the permanent neural stimulator, along with 63685 (incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling).

A modifier must be attached to the second electrode or paddle/plate code to eliminate the appearance of duplicate billing. The choice of modifier depends on the length of time spent during the testing stage of the procedure.

Susan Callaway-Stradley, CPC, CCS-P, a coding consultant and educator in North Augusta, S.C., says, If both stages of the procedure, the testing and the permanent implantation, are performed on the same day, use modifier -59 (distinct procedural service). This should prevent the carrier from bundling the second electrode or paddle/plate code into the testing procedure.

Modifier -58 (staged or related procedure or service by the same physician during the postoperative period) should be used if the testing takes longer and the permanent implantation is done on a separate day.

At the time of permanent implantation the neurostimulator pulse generator/transmitter must be programmed according to the data collected during the test stage. The length of time necessary for the programming varies depending on the number of tests the neurosurgeon must perform and the patients responses. Time-based codes are used for billing this portion.

For the first hour, the physician should use 95972 (complex brain, spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming). For each additional half-hour, use 95973 (complex brain, spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming).

4. Maintenance or Removals

Approximately three to five years after the permanent implantation of the spine stimulator and generator, the patients battery will have to be removed and replaced. Implantation code 63685 should be used for this procedure.

If the physician or patient decides that the neurostimulator is not working and needs to be removed, the following codes should be used to bill for the extraction of the electrode or plate/paddle and the generator:

63660 (revision or removal of spinal neurostimulator electrode percutaneous array[s] or plate/paddle[s])

63688 (revision or removal of implanted spinal neurostimulator pulse generator or receiver)

5. Multiple Stimulators

Occasionally, a patient may have chronic pain in several regions. Therefore, more than one neural stimulator must be implanted. The coding example previously given would be followed with these additions:

For the trial stage, bill either 63650 or 63655 twice. The neurosurgeon should attach modifier -51 (multiple procedures) to the second occurrence of the code.

For the permanent implantation stage, again bill either 63650 or 63655 twice, adding modifier -58 to the first occurrence of the code in this stage to prevent bundling and modifiers -58 and -51 modifier to the second.

6. Coding for VNS and Intercranial Stimulators

Petruziello reports that there are variations in coding for vagal nerve and intercranial stimulators. A vagal nerve stimulator is implanted on a cranial nerve but not in a cranial area to treat epilepsy. For vagal nerve stimulators, the primary procedure code for the testing stage is 64573 (implantation neurostimulator electrodes, cranial nerve, vagal nerve stimulation). If the permanent implantation of the neural stimulator is done on the same day use 64573 again and append modifier -59 (distinct procedural service); if the permanent implantation of the neural stimulator occurs on a different day append modifier -58. Code 61885 (incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array) describes placement of the generator.

A deep range intercranial stimulator will be implanted in the cranial area for the treatment of Parkinsons disease and tremors.

For deep intracranial procedures, the primary procedure code for the testing stage is 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]). If the permanent implantation of the neural stimulator is done on the same day use 61862 again and append modifier -59; if the permanent implantation of the neural stimulator occurs on a different day append modifier -58. Code 61885 describes the placement of the generator.

Additionally, a neurosurgeon may use a computer navigational device during intercranial surgeries. If so, he or she should bill 61795 (stereotactic computer assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal).

Stradley suggests that coders become familiar with Medicares guidelines regarding these procedures. Many carriers follow these guidelines or use them as a starting point when creating their own reimbursement perimeters.