Neurosurgery Coding Alert

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:

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. 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 [...]