Urology Coding Alert

After exhausting conventional therapies, urologists must first "implant a temporary lead to confirm that the patient gets feeling from the leads," Littrell says. According to the national coverage determination (NCD), this preliminary test, called percutaneous nerve evaluation (PNE), has to demonstrate at least a 50 percent reduction in symptoms to be considered successful, in which case a permanent lead and generator would be implanted. To code the temporary leads, use 64561 (Percutaneous implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]).

"Typically, two temporary leads are placed 'bilaterally'to test whether one side is more effective than another and a prime location for the permanent lead," Littrell says. But don't use the bilateral modifier, -50, to indicate that the leads were placed bilaterally, she instructs coders. Though the leads are referred to as "bilateral," they are actually on both sides of the spinal cord.

"Code the first temporary lead with 64561 and each additional temporary lead with 64561-50, each on a separate line." Don't be surprised if a third lead is placed in addition to the bilateral leads for testing purposes, she says. During the temporary lead testing, no generator is implanted, but an external device stimulates the sacral nerves to produce bladder contractions.

Proper coding for temporary lead treatments prior to permanent SNS treatment also includes reporting add-on code +95920 (Intraoperative neurophysiology testing, per hour [list separately in addition to code for primary procedure]) and 95926 (Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs) for the tests that are required to determine whether the leads are working.

When done in a facility setting, "you must append modifier -26 to both test codes, 95920 and 95926, to indicate the urologist performed strictly the professional component," Littrell says. She also instructs coders to bill 76000-26-50 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) for the fluoroscopy used by the urologist for the interpretation of the tests.

"Medicare will not allow you to bill 95920 and 95926 for the testing of the temporary leads," Littrell says, so for Medicare patients undergoing the preliminary tests for SNS you should bill only for the temporary leads and the fluoroscopy.

If the temporary treatment succeeds, you will need to know how to code the two stages that make up permanent SNS treatment.

In stage one, the urologist implants one permanent lead that is tested before implanting a permanent generator. You will need to use 64581 (Incision for implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]) for the permanent lead, Littrell says, and as with the temporary lead, you will need to use a testing code. Report 95972-26 (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]; complex brain, spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour) for the professional component of the testing of the permanent lead, she says, and don't forget to code the fluoroscopy, 76000-26-50.

Once the urologist gets a positive result from the permanent lead testing, a permanent generator will be implanted in the patient. You will need to use 64590-58 (Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling), Littrell says. Unlike the temporary lead implant, which has a 10-day global period, the permanent lead implant has a 90-day global period, which means the second-stage generator implant procedure requires modifier -58 (Staged or related procedure or service by the same physician during the postoperative period). Once again, you need to report a code for the testing of the generator, 95972-26, and the fluoroscopy code 76000-26-50.

Occasionally, problems arise with the lead and/or the generator after they are implanted for sacral nerve stimulation therapy.

For example, a patient presents with urinary retention and the urologist evaluates the patient, determining she is a prime candidate for SNS. However, after the lead and generator are implanted, one of the two components malfunctions. To code the removal of the permanent lead, you should report 64585 (Revision or removal of peripheral neurostimulator electrodes), Littrell says, and for the removal of the generator, use 64595 (Revision or removal of peripheral neurostimulator pulse generator or receiver). The applicable diagnosis code in this case is 996.75 (Other complications of internal [biological] [synthetic] prosthetic device, implant, and graft; due to nervous system device, implant, and graft).

In another example, a patient presents with urge incontinence and proves to be a candidate for SNS. Two months after the implantation of the generator, the patient presents with severe infection from one of the implanted permanent devices. As in the previous example, use 64585 for the removal of the permanent lead and 64595 for the removal of the permanent generator. When an infection is the primary source of the complication, Littrell says, you may also need to report a code for debridement of the infected skin, i.e., 11042 (Debridement; skin, and subcutaneous tissue). The applicable ICD-9 code for an infection from an SNS implant is 996.63 (Infection and inflammatory reaction due to internal prosthetic device, implant, and graft; due to nervous system device, implant, and graft).