Part B Insider (Multispecialty) Coding Alert

Treat the trial and final implantation as staged procedures

A patient comes in with chronic intractable pain, and the physician has tried other treatment methods, including drugs. What do you do?
 
These days, Medicare covers spinal neurostimulator implantation for last-ditch pain relief. But the Part B carriers require you to test the leads on the patient to see if they reduce the pain, before doing a final implantation. Many coders aren't sure how to bill for the test and final implantation without falling afoul of a 90-day global period.
 
The best approach is to treat the test and final implantation as a staged procedure, using modifier -58 (Staged or related procedure or service by the same physician during the postoperative period), says Devona Slater, president of Auditing for Compliance & Education in Leawood, Kan. For example, the physician may perform a percutaneous placement (63650) for trial purposes. Then two weeks later, the physician does the permanent placement. In that case, bill 63650 again, using modifier -58, along with 63685 (Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver).
 
Don't use modifier -59 (Distinct procedural service) unless the later implantation is on a different site on the body, says Rhonda Petruzillo, director of revenues and reimbursement for medical operations with Metro Health Medical Center in Cleveland. Since the physician knows in advance she's going to have to implant a permanent neurostimulator after the test, it's more like a staged procedure than a separate and unrelated procedure.
 
The physician's operative note for the first procedure should mention that this is a staged procedure and that the final implantation will happen later. Unless the op notes for the first procedure mention that the physician expects a follow-up, some carriers may not pay for the later procedure even with modifier -58.
 
Don't forget that you can bill per electrode for multiple electrodes, Slater says. "Coders miss [out on] billing that code multiple times," she says. You don't necessarily need a modifier if you bill 63685 multiple times. But if the carrier questions it, Slater advises using modifier -51 (Multiple procedures).
 
If you're doing a bilateral neurostimulator placement, use modifier -50 (Bilateral procedure), Petruzillo says. With Medicare, you should only bill on one line item, using 63685 with modifier -50 in a quantity of one. The carrier will automatically add the extra reimbursement for the bilateral procedure. Some other payers, such as Blue Cross/Blue Shield plans, want to see 63685 billed twice, with modifier -50 attached to the second instance. And some payers want to see 63685 on one line, with a quantity of two and modifier -50.
 
If you provide the neurostimulators in the office setting instead of the hospital, you'll need a durable medical equipment supplier number to bill for the equipment and supplies, Slater says.