Neurosurgery Coding Alert

Question: I notice that the descriptors for 64555 and 64575 have changed for 2002. How will this affect coding for placement of neurostimulators?

Colorado Subscriber  
Answer: For 2002, the descriptors for neurostimulator placement codes 64555 (Percutaneous implantation of neurostimulator electrodes; peripheral nerve [excludes sacral nerve]) and 64575 (Incision for implantation of neurostimulator electrodes; peripheral nerve [excludes sacral nerve]) have been revised to specifically exclude the sacral nerve. CPT has added two new codes to report placement of a neurostimulator on the sacral nerve: 64561 (Percutaneous implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]) and 64581 (Incision for implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]).
 
According to the AMAs CPT Changes 2002: An Insiders View, 64561 and 64581 were added for treating voiding dysfunction (e.g., urge incontinence, urgency-frequency and nonobstructive retention) by direct stimulation of the sacral nerve accomplished by transforaminal placement through a sacral foramen. Codes 64555 and 64575 still apply in all other circumstances.
 
Regardless of the nerve(s) involved, or whether it is a percutaneous or incisional procedure, they are performed prior to and reported separately from the actual placement (64590 or 64595) of the implantable pulse generator, or IPG. The time between the incision and placement of the IPG may span from several days to a month. Because this is a prospectively planned operation that requires a return to the operating room, attach modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the appropriate implantation code.
 
Although many payers have not yet published local medical review policies (LMRPs) addressing 64561 and 64581, those that have allow relatively few diagnoses to prove medical necessity for these procedures. For instance, Wisconsin Physicians Service, a Medicare carrier for Wisconsin, Illinois, Michigan and Minnesota, lists only six acceptable diagnoses in its LMRP for sacral nerve stimulation: 596.55 (Detrusor sphincter dyssynergia), 596.59 (Other functional disorder of bladder), 788.20 (Retention of urine, unspecified), 788.21 (Incomplete bladder emptying), 788.31 (Urge incontinence) and 788.41 (Urinary frequency).
 
Documentation requirements specify that the patient must be unresponsive to conventional therapy. Conventional therapy consists of pharmacological treatment (e.g., two different anticholinergic drugs or a combination of an anticholinergic and tricyclic antidepressant) and/or behavioral therapy (e.g., pelvic muscle exercises, behavior modification, biofeedback, time void and fluid management). In addition, Wisconsin Physicians Services LMRP places the following limitations on coverage for sacral nerve stimulation:

  Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) associated with secondary manifestations of the above three indications are excluded.

  Patient must have had a successful test simulation to support subsequent implantation. Before a patient is eligible for permanent implantation, he or she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement [...]