Eli's Rehab Report

CMS delivered a double treat to PM&R practices in July, issuing new electrical stimulation coverage policies for treating pressure ulcers and helping spinal cord injury patients walk.

Although the spinal cord treatment is referred to as "neuromuscular electrical stimulation" (NMES), it should not be coded with 64565 (Percutaneous implantation of neurostimulator electrodes; neuromuscular). Instead, both of the new policies refer to services billed using the PM&R code 97032 (Application of a modality to one or more areas; electrical stimulation [manual], each 15 minutes).

Attended Versus Unattended Modality

On July 22, CMS announced that it would expand coverage of NMES "to assist people with spinal cord injuries in walking." Neuromuscular electrical stimulation (NMES) allows a therapist or physician to hold a device over a patient's skin to deliver electrical impulses to the patient's muscles.

On July 23, CMS issued a decision memorandum stating that electrical stimulation will be covered for patients whose chronic stage III and IV pressure, arterial, diabetic and/or venous stasis ulcers have not healed after at least 30 days using standard wound therapy.

Note: As of press time, CMS had not released specific ICD-9 Codes approved for coverage under these new guidelines. Refer to your local carrier's LMRP guidance to determine whether your patient's diagnosis code is applicable.

These types of electrostimulation should be coded with 97032, which is classified as a "constant attendance" modality in CPT and, therefore, requires direct patient-to-provider contact. Confusion often occurs when coders consider other electrical stimulation codes, such as 97014 (Application of a modality to one or more areas; electrical stimulation [unattended]). This code, however, refers to a therapy modality that does not require the presence of a clinician, says John Whitemore, PT, a physical therapist in Duluth, Ga.

"The biggest difference between 97032 and 97014 is that the therapist or physician must stay with the patient during the attended code [97032]," Whitemore says.

"Another big difference is that 97014 is not a time-based code, so you should only bill it once per session. Even if the patient receives unattended electrical stimulation for 45 minutes, you would bill only one unit of 97014, whereas 45 minutes of 97032 would be billed as three units."

NMES Is Different From TENS

Therapists occasionally use a form-fitting garment that delivers NMES electricity directly to the patient. This product can be coded as E0731 (Form-fitting conductive garment for delivery of TENS or NMES [with conductive fibers separated from the patient's skin by layers of fabric]).

Because the descriptor for E0731 includes the word "TENS," some therapists believe that TENS and NMES are synonymous. However, TENS refers to transcutaneous neurostimulators, which physiatrists sometimes use to anesthetize nerves to control or block pain. TENS should be coded as 64550 (Application of surface [transcu-taneous] neurostimulator).

"TENS coding is subject to even further confusion because most carriers' LMRPs advise billing 97032 one or two times when training the patient on how to use TENS at home," says Melissa Humphrey, coding and billing coordinator at Warren Rehabilitation in Orlando, Fla. "Remember that 97032 is only used when training a patient on TENS. Actual application of TENS is billed using 64550."

Some practices skim the descriptors listed under TENS in CPT and see "neuromuscular" listed, "and they'll accidentally choose 64565 for NMES," Humphrey says. "Obviously, 64565 is for implantation of electrodes. NMES is a therapy modality."

According to the December 1998 CPT Assistant, the 15-minute time frames referenced in the supervised modality code descriptors (such as 97032) "describe the total time, i.e., pre-service, intra-service, and post-service time spent in performing the modality."

Therefore, if the therapist examined a patient before performing the electrical stimulation to determine whether his condition changed since his last visit, that examination would be counted as "pre-service" minutes and would be included in the total time spent with the patient.