Eli's Rehab Report

Nugget: The Freehand System for quadriplegic patients is new and billers must choose from among many codes, but physicians providing the system to their patients are being reimbursed by private payers.

Implantable products that improve function for spinal cord injury patients are becoming more readily available now that insurers are beginning to recognize their usefulness. One product in particular, the NeuroControl Freehand System, which allows paralyzed patients to grasp and release with their hands, is making its way into more rehabilitation centers. The dilemma, however, comes when billing offices are unsure how to make sense of the many codes that are used in conjunction with these relatively new devices.

Freehand System Description

The NeuroControl Freehand System is an implantable device that allows quadriplegic patients to use a paralyzed hand to grasp and release objects. This is applicable to patients with spinal cord injury at level C5 and C6 who can demonstrate an upper motor neuron paralysis to certain forearm muscles and who have met specific evaluation criteria for functional goals and physical status by the rehabilitation team, say Judith G. Lazar, FACMPE, administrator, and Daniel P. Lammertse, MD, medical director at Craig Hospital in Englewood, Colo., which specializes in rehabilitation and research for patients with spinal cord and brain injuries. To date, Craig Hospital has implanted the Freehand System into four patients.

The Freehand System operates by sending signals from small shoulder movements, detected through a shoulder-positioned sensor, into a controller. The controller, usually located on the patients wheelchair, receives the signal and sends radio waves to the surgically implanted stimulator, usually worn in the chest, which sends electrical stimuli to eight electrodes attached to paralyzed hand and forearm muscles, causing the hand muscles to contract so the patient can grasp and release objects. These patients may now be able to eat, drink, write, type, brush their hair, and perform other tasks that they could not previously perform.

Allowable Diagnoses for the Freehand System

Terri Zmina, PT, MBA, reimbursement specialist at NeuroControl Corp. in Cleveland, the company that makes the Freehand System, states that the product can be used in patients with C5-C7 level spinal cord injuries (ICD-9 952.06 ) and quadriplegia, C5-C7 complete (ICD-9 344.03 ). From the physical medicine and rehabilitation (PM&R) physicians perspective, patients must first be evaluated to make sure they are good candidates for Freehand System implantation, which, according to Zmina, is used in patients who meet the following requirements:

have use of their shoulder, upper arm and elbow, but who may not have use of their wrist and who have limited use of their hands;

have adequate range of motion with forearm and hand muscles that respond to stimulation by electrical impulses; and

are skeletally mature.

The surgical aspect of the Freehand System implantation is normally done by a hand surgeon, says Zmina, though the analysis of the implanted stimulator often is performed by an occupational therapist.

Following the Freehand implantation, there is a prescribed therapy follow-up schedule for the Freehand System, say Lazar and Lammertse. The patient must go through training and rehabilitation to learn how to use the system. This postoperative rehabilitation can be done either on an inpatient basis at a rehabilitation hospital or on an outpatient basis, depending on the needs of the patient and complicating factors.

The Freehand Systems implanted components permanently remain in the patient, says Zmina, though the external components require periodic replacement and upgrading due to normal wear and tear.

Coding advice for the preliminary evaluation, the implantation procedure and the follow-up rehabilitation is listed in the accompanying box, Coding Tips for the Freehand System, below.

Check With Insurer Before Implantation

We have been reimbursed for the Freehand System by some private insurers, says Lazar, who always ensures insurance preauthorization before Craig Hospital proceeds with implantation. But she cautions that Medicare may not pay as well as private insurers. While Medicare may reimburse for the implant procedures, the reimbursement may be inadequate considering the cost of the expensive implanted equipment, for which there is no separate Medicare reimbursement.

Zmina notes that the Freehand System does not yet have its own HCPCS code. Practices considering use of the Freehand System should always check with their insurers before proceeding with an implantation.