Radiology Coding Alert

Selecting the proper sacral nerve stimulator codes is no simple feat, but a close look at payer instructions can point you in the right direction.

What is it? "A sacral nerve stimulator is a pulse generator that transmits electrical impulses to the sacral nerves through an implanted wire. These impulses cause the bladder muscles to contract, which gives the patient ability to void more properly,"states Medicare Claims Processing Manual (MCPM), Chapter 32, Section 40 (www.cms.gov/Manuals/IOM/list.asp). You might also see the terms sacral nerve neuromodulation  or InterStim Therapy (the Medtronic device brand name) in relation to this service.

Good news: For certain coverage conditions, CMS has approved the sacral nerve stimulator procedure for urinary incontinence, and the service seems to be growing in popularity, says Jolynn M. Van Ert, RT(R)(T), CPC, CIRRC, radiology support specialist with the Luther Midelfort radiology department in Eau Claire, Wis. Several private payers cover the service, as well.

For accurate claims, you need to know how to code both the temporary lead insertion procedure and the subsequent permanent lead and device insertion, says Van Ert. And you might see programming and removal services, too. Here are the details.

The first stage in the process involves a minimally invasive test simulation, which allows patients to determine whether they could benefit from permanent implantation.The patient keeps a diary of their "voiding behavior" for several days.

To report the temporary lead placement, use 64561 (Percutaneous implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]), states the Blue Cross & Blue Shield of Rhode Island (BCBSRI) sacral nerve stimulation medical coverage policy (www.bcbsri.com/BCBSRIWeb/plansandservices/services/medical_policies/SacralNerveStimulation.jsp).

Watch for: Medtronic's January 2010 "InterStim Therapy for Urinary Control:Commonly Billed Codes" notes that FDA labeling requires percutaneous test simulation, but if that test is inconclusive, then the physician may choose to use the surgical lead for test simulation (http://professional.medtronic.com/downloads/reimbursement/Interstim_Commonly_Billed_Codes_Combined_Jan_Feb_2010_NI9805.pdf). The code for that service is the same as for the permanent lead placement, 64581 (Incision for implantationof neurostimulator electrodes; sacral nerve [transforaminal placement]).

Tip: The Medtronic document notes that you may consider reporting 76000 (Fluoroscopy [separate procedure], up to 1 hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) separately with the tined lead placement (64581). But just recently the Correct Coding Initiative (CCI) made it clear that youshould not report fluoroscopy with 64561. The most recent CCI version, effective April 1, bundles fluoroscopy codes 76000-76001 (Fluoroscopy ...) and 77002-77003 (Fluoroscopic guidance ...) into 64561. The edits have a modifier "1" indicator, which means you'll have to append -- and justify --" a modifier on the fluoroscopy code to separately report both procedures.

Code 64561 describes a percutaneous procedure, so the physician "has to have some way to visualize the placement," points out Jan Rasmussen, CPC, AGS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis. But be sure you heed the new edit in your coding.

Also remember that edits only apply to services performed by a single physician submitted on a single claim. So if you're coding for a radiologist who provides fluoro for another physician performing the 64561 procedure, the edits would not prevent you from reporting the fluoro code.

If the test stage proves the patient is a good candidate, the next step is permanent implantation of the electrode and pulse generator. The BCBSRI policy explains that you report two codes for this service. For the electrode implant, you should report 64581. Then report a separate code for the pulse generator insertion: 64590 (Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling). Be sure you report codes only for the services the radiologist performs.

If the radiologist provides fluoroscopy for the procedure, you should be able to report that separately.

If your practice performs device analysis and programming/reprogramming, you'll have more codes to consider. Caution: If a device representative performs the service, you should not code it (or charge the patient for it).

BCBSRI recommends the following codes if you do perform the service:

• 95970 -- Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming
• 95972 -- ... complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour
• +95973 -- ... complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure).

You should report 95970 for analysis without reprogramming. Code 95972 is appropriate for analysis and the first hour of intraoperative programming or subsequent reprogramming at a later visit. For each additional 30 minutes of programming/reprogramming after the first hour, you may report +95973 in addition to the primary code.

At some point, the patient may require removal of the lead (electrode) or pulse generator. If your radiologist removes just the lead, you should report 64585 (Revision or removal of peripheral neurostimulator electrodes). If he also removes a generator, you should report 64595 (Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver), as well.

Note: If the patient is still in a 90-day global period from the initial insertion, you may need to append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for arelated procedure during the postoperative period) to the procedure code. For example, the patient may require removal if a part of the device malfunctions.