Urology Coding Alert

Capture both lead placement and testing for each step of the process.

When conventional treatments like pelvic floor exercises, diet changes, and drug therapy do not improve a patient’s urinary dysfunctions, your urologist might turn to sacral nerve stimulation (SNS). Complex three-stage placement procedures, testing codes, and recent code changes make SNS therapy coding a challenge. Focus on three steps to ensure you don’t miss any of the reimbursement opportunities or fall into the pitfalls of coding these procedures.

1. Learn the SNS Background

SNS is a procedure that uses implanted devices to stimulate the sacral nerves, which in turn causes bladder muscle contraction. SNS uses permanent implanted leads, or wires, and an implanted generator to deter complications such as ureteral reflux, upper urinary tract damage, and infection that can result from urinary disorders.

SNS is often used for patients with loss of bladder function control that results in one of the following indications: urge incontinence (788.31), urinary urgency-frequency syndrome (788.41), and non-obstructive urinary retention (788.20), says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia.

“SNS was first approved by the FDA for the treatment of urinary urge incontinence in 1997,” says Nina Mutone, MD, MPH, urogynecologist with Urology of Indiana in Indianapolis. “In 1999 it was approved for urgency/frequency syndrome as well as non-obstructive urinary retention. In 2012 SNS was approved for the treatment of fecal incontinence. For all indications SNS is reserved for cases in which conservative treatments (diet, behavioral therapy, medications etc) failed.”

CMS outlines the following limitations for coverage of SNS for patients with established diagnoses of urge incontinence, urinary urgency-frequency syndrome and urinary retention: “Patient must have had a successful test stimulation in order to support subsequent implantation.”

After exhausting conventional therapies, urologists must first implant a temporary lead. “When the decision is made to offer SNS, a test stimulation must be performed first,” Mutone explains. “The purpose of the test stimulation is to confirm a therapeutic response.”

There are two ways to perform this test stimulation, Mutone says: One is placement of a temporary lead connected to a temporary external generator, and the other is step 1 of a two-stage permanent placement. Your coding will differ depending on what procedure your urologist performs.

2. Focus on 64561 for Temporary Lead Placement

According to the national coverage determination (NCD), the preliminary test with temporary placement, 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 lead placement, you should report 64561 (Percutaneous implantation of neurostimulator electrode array; sacral nerve [transforaminal placement] including image guidance, if performed), Boone says.

Bilateral distinction: Often the urologist will place temporary leads bilaterally to test whether one side is more effective than another and a prime location for the permanent lead. “In this case, you should report 64561 with modifier 50 (Bilateral procedure),” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

Don’t miss: In addition to the placement, your urologist will perform tests to determine whether the leads are working. You should code for this service as well. If you are billing a private (non-Medicare) payer, report 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) along with the appropriate one of the following add-on codes if clinically indicated:

+95940 — Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure)

+95941 — Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure).

Note that in the past you would have used +95920 (Intraoperative neurophysiology testing, per hour [list separately in addition to code for primary procedure]) but CPT® deleted this code on Jan. 1, 2013.

When done in a facility setting, you must append modifier 26 (Professional component) to 95926 to indicate the urologist performed strictly the professional component of the service. Add-on-codes +95940 and +95941 do not require the addition of modifier 26.

Radiology: The urologist typically uses fluoroscopic guidance for the placement procedure. In the past, coders would have used 76000 (Fluoroscopy [separate procedure], up to 1 hour physician or other qualified health care professional time, other than 71023 or 71034 [eg, cardiac fluoroscopy]) or 77002 (Fluoroscopic guidance for needle placement [eg, biopsy, aspiration, injection, localization device]) with 64561, says Cheryl A. Schad, BA Ed, CPC, ACS-RA, PCS, president/CEO of Schad Medical Management in Mullica Hill, NJ. New way: CPT® 2013 revised the descriptor of 64561 by adding the underlined text: Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed.

“There is no longer a radiology component associated with this procedure,” Schad explains. “All imaging guidance is now included in this procedure and should not be reported separately when performed.”

3. Stage 1 of Permanent Placement Calls for 64581

“Because of instability (loss of the lead from its cutaneous site) and unreliable function of a percutaneous lead, your urologist may opt to skip the percutaneous lead implantation altogether and instead perform a staged procedure,” Ferragamo says. “However, when a temporary SNS recording reveals a 50 percent reduction in symptoms, your urologist may then also decide to move directly to a permanent SNS treatment.” There are two stages that make up a permanent treatment.

In stage one, the urologist implants one permanent lead. He then tests that lead before implanting a permanent generator. You will need to use 64581 (Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement]) for the permanent lead placement.

This procedure is done in the hospital under fluoroscopic guidance and the lead is connected to a temporary external generator, Mutone explains. Report 77002-26 (Fluoroscopic guidance for needle placement [eg, biopsy, aspiration, injection, localization device]) for the fluoroscopic guidance used for the permanent lead implantation, Ferragamo says.

As with the temporary placement of the lead, your physician will test the function and accurate placement of the lead. For non-Medicare payers you should report this service with 95926, and if performed +95940 or +95941.

4. Turn to 64590 for Stage 2 Generator Implantation

Once the urologist sees a positive result (50 percent reduction in patient symptoms) from the implanted lead testing, he will move to the second stage: a permanent generator implantation. You will use 64590 (Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling). This procedure is also typically done in the hospital.

Pointer: “If the PNE was used for the test stim, and it is successful, the patient goes on to permanent implant of the permanent lead and IPG (implanted battery) with both steps done at the same time (64581 + 64590),” Mutone says.

Modifier must-have: Unlike the temporary lead implantation code, which has a 10-day global period, the permanent lead implantation code carries a 90-day global period. That means you should attach modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to 64590 if you are within the 90-day global period, which often happens, Ferragamo explains.

Additionally, you need to report a code for the programming of the generator along with this placement coding. Use 95971 (Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming) or 95972 (… complex spinal cord, or peripheral [ie, peripheral nerve, sacral nerve, neuromuscular] [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour).

Stay tuned: Watch for an article next month in Urology Coding Alert that explains the coding for removal and reimplantation of SNS leads and generators.