Neurosurgery Coding Alert

Answer: Medicare and most third-party payers recommend 20975 (Electrical stimulation to aid bone healing; invasive [operative]) for internal bone stimulators. Generally, the physician performs a fusion such as 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]) at the same time.

The internal stimulator is only covered for nonunion of long bone fractures, and as an adjunct to spinal fusion surgery, etc. Nonunion of long bone fractures, for both invasive and noninvasive devices, no longer exists when serial radiographs confirm that fracture healing has ceased for three or more months prior to starting treatment with the stimulator. Serial radiographs must include a minimum of two sets, each having multiple views of the fracture site, separated by a minimum of 90 days. ICD-9 code 733.82 (Nonunion of fracture [pseudoarthrosis] [bone]) is the most commonly accepted diagnosis associated with internal or external bone stimulators.

Payers will bundle follow-up for the internal bone stimulator in the 90-day global period of the fusion code.

For external bone stimulators, report 20974 (Electrical stimulation to aid bone healing; noninvasive [nonoperative]). But Medicare argues that there is insufficient evidence to support the medical necessity of using a stimulator for treating nonunions of the skull, vertebrae or those that are tumor-related. And Medicare will not cover ultrasound stimulation for fresh fractures. Coverage guidelines for Medicare may be different from the coverage criteria of many private insurers. Ask your local carriers for more details.

Payers will cover an external bone stimulator for nonunion of long bone fractures; for failed fusion, when a minimum of nine months has elapsed since the last surgery; for congenital pseudarthroses; and as an adjunct to spinal fusion surgery for patients at high risk of pseudoarthrosis due to previously failed fusion at the same site or for those undergoing multiple-level fusion. You may report follow-up for an external bone stimulator using codes for standard office visit E/M (99211-99215).