Neurosurgery Coding Alert
Updated Sacral Nerve Stimulation Coverage Stresses Proper Documentation
Medicare recently revised and consolidated its coverage of sacral nerve stimulation for urinary urge incontinence and other conditions. Documentation requirements remain stringent, however, and neurosurgeons must be certain to supply all necessary information to receive appropriate reimbursement. Document a Covered Condition As explained by Medicare program memorandum AB-03-028, change request 2532 (Feb. 28, 2003) which consolidates and supercedes change requests 1936 (Nov. 15, 2001) and 2098 (March 21, 2002) a sacral nerve stimulator is "a pulse generator that transmits electrical impulses to the sacral nerves through an implanted wire." The impulses cause the bladder muscles to contract, thereby giving the patient the ability to void properly. Since Jan. 1, 2002, Medicare has covered sacral nerve stimulation for the treatment of three conditions: urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Medicare excludes coverage for patients with stress incontinence, urinary obstruction, and specific neurologic diseases (for example, diabetes with peripheral nerve involvement) that are associated with secondary manifestations of any of the above three indications. Medicare also stipulates the following conditions for coverage, which the physician must carefully document in the medical record: Conservative forms of treatment for urge incontinence (both of which must be documented) are pharmacological (for example, two different anticholinergic drugs or a combination of an anticholinergic and tricyclic antidepressant) and behavioral (for instance, pelvic muscle exercises, behavior modification, biofeedback, timed voids or fluid management). Conservative forms of treatment for idiopathic nonobstructive chronic urinary retention include pharmacological treatment (for example, the use of alpha blockers and cholinergics) and either self- or indwelling catheterization. The patient must have had a successful test stimulation 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 is measured through voiding diaries (see below). Note that a test simulation is an integral part of sacral nerve stimulation and is a covered service under Medicare for the indications noted above. The patient must demonstrate adequate ability to record voiding diary data so clinical results of the implant procedure can be properly evaluated. Report All Portions of the Procedure Implantation of the neurostimulator and associated hardware involves several steps. Initially, the physician must place test leads for an external neurostimulator, which you should report using HCPCS Level II code A4290 (Sacral nerve stimulation test lead, each). When placing more than one lead, use the "units" box of the CMS-1500 claim form to indicate the exact number placed (for instance, for three leads, report A4290 and place a "3" in the units box). The neurosurgeon can place the electrodes (which deliver the charge) either percutaneously or via incision. Report this service separately using either of the following codes, as appropriate: Report only one unit of either 64561 or 64581 regardless of the number of electrodes placed. Following testing with an external generator, report placement of an implantable generator (which supplies the charge) separately using 64590 (Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling). Note that the time between the incision and placement of the generator and prior placement of the neurostimulator electrodes 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 implantation code. You may recover the cost of the neurostimulator equipment (if supplied by the physician) using E0752 (Implantable neurostimulator electrodes, each) and E0756 (Implantable neurostimulator pulse generator). Use E0752 to report each electrode. As with A4290, use the units box of the claim form to indicate the total number of electrodes placed. Never bill multiple units of E0756 because only a single generator is necessary. CPT provides two codes for revision or removal of the neurostimulator components, which you may report separately should either be required: Programming Is (Sometimes) Separate Following implantation, the surgeon typically tests the device and leads and sets the initial programming parameters, both in the operating room and in the office during the days and weeks following the implant, says Petrina White, CPC, coding specialist in the department of neurosurgery at Vanderbilt University Medical Center in Nashville, Tenn. For example, a typical Medicare local medical review policy (LMRP) explains, "[Because] patients require some time to build up tolerance for optimal stimulation, the pulse generator needs to be programmed/analyzed or adjusted [more frequently] in the first 18 months. ... the generator is programmed intra-operatively, 'ramped up'two weeks later, and adjusted thereafter until optimal efficacy is achieved." According to CPT, a simple neurostimulator (for example, 95970 and 95971) controls three or fewer of the following stimulus parameters: pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, phase angle, alternating electrode polarities, configuration of wave form or more than one clinical feature. A complex neurostimulator (such as 95972 and 95973) affects more than three of the above. Generally, only simple reprogramming is required for sacral nerve stimulation, although the physician must still document the stimulus parameters he or she adjusted, says Frank Falco, MD, an AMA CPT editorial board member representing the American Academy of Physical Medicine and Rehabilitation. CPT states that the codes for surgical implantation of a pulse generator do not include evaluation, testing, programming or reprogramming. WPS Medicare Part B for Illinois and Michigan (policy NEURO-004), for example, states, "General practice is for the neurosurgeon alone to bill for the surgery A separate procedure code for electronic analysis services (95974 or 95975) may be appropriate if the neurologist/neurophysiology team adjusts and initiates initial stimulus levels in the operating room." Nevertheless, this implies that the analysis and reprogramming are payable only if performed by a physician of another specialty rather than the operating neurosurgeon. Not all payers follow CPT guidelines, however. Blue Cross/Blue Shield North Dakota's LMRP says, "Adjustments during the initial 90 days after implantation are considered to be part of the global period." And the National Correct Coding Initiative (NCCI) and many Medicare LMRPs bundle simple analysis/programming to pulse generator placement but will allow you to bill separately for complex pulse generator programming. Because of the variability of coverage limitations and bundling issues, be sure to contact your individual carrier for its guidelines prior to billing.
The patient must be refractory (that is, unresponsive) to conventional therapy and be an appropriate surgical candidate so implantation with anesthesia can occur. The physician must note these conditions including specifically prior, unsuccessful behavioral, pharmacologic, and/or surgical corrective therapy clearly and completely in the medical record.
64581 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement).
CPT supplies several codes to describe these services:
95971 simple brain, spinal cord, or peripheral (i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intra-operative or subsequent programming
95972 complex brain, spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/ transmitter, with intraoperative or subsequent programming, first hour
+ 95973 each additional 30 minutes after first hour (list separately in addition to code for primary procedure).
Neurosurgery Coding Alert
- Updated Sacral Nerve Stimulation Coverage Stresses Proper Documentation
Medicare recently revised and consolidated its coverage of sacral nerve stimulation for urinary urge incontinence [...] - Global Periods, Part 2:
To Bill or Not to Bill Post-Op Complications?
Although not uncommon, complications following surgery are an uncommonly troublesome coding challenge. Because the CPT [...] - News You Can Use:
Medicare Payments Rising, but Expect Some Challenges
On Feb. 28, Medicare published an update to its final rule for the 2003 Physician [...] - You Be the Coder:
Simple or Complex Aneurysm?
Test your coding knowledge. Determine how you would code this situation before looking at the [...] - Reader Question:
Insurer Has Final Say on Modifiers
Question: An insurer instructed us to use modifier -76 when coding second and subsequent levels [...] - Reader Question:
Report 63045-63048 per Segment
Question: Is it appropriate to report laminectomy codes 63045-63048 per segment or per interspace? CPT [...] - Reader Question:
Unlisted-Procedure Code for Osteophytectomy
Question: The surgeon removed an osteophyte from the cervical spine that was compressing the hypopharynx. [...] - Reader Question:
BMP Is Included in Fusion
Question: The surgeon dictated that he used "BMP" during fusion. What is this, and how [...]
