Spinal Cord Stimulation

The proper current procedural technology (CPT) coding for the trial and permanent stimulator procedures is listed in Table 23-1.² All patients must meet clinical criteria, and medical necessity should be documented extensively in the patient record. Note that billing for removal of the trial percutaneous leads is not appropriate if no surgical incision and no surgical anchoring were performed in the initial placement. These codes were created specifically for trial leads that were placed using the “cut-down” technique. The global period for the listed surgical codes is 10 days. Wound checks and physical examinations are not typically billable for the first 10 days after placement of the spinal cord stimulation (SCS) system.

Table 23-1 Neurostimulator Current Procedural Technology Codes

Peripheral Nerve Stimulation

The proper CPT coding for the placement of trial and permanent peripheral nerve stimulators is listed in Table 23-2.² To bill these codes the patient should meet clinical criteria, and medical necessity should be well documented in the record. Please note that it is inappropriate to bill for the removal of the percutaneous electrode leads placed for the trial that are removed in the office setting. The removal codes are intended for leads that have been placed by surgical cut-down and require open surgical removal. Remember that it is appropriate for the physician to bill for the array, not the electrodes. Therefore, if two arrays are tunneled separately to provide stimulation to dual areas, the practitioner can attach either the 51 (multiple procedures) or 59 (distinct procedural service) modifiers, per carrier requirements. The surgical codes listed in the table fall under the 10-day global period. As with SCS, this period applies to wound checks, examinations, and other areas of management regarding the peripheral nerve stimulation system. In some cases insurers do not understand the procedure being performed with peripheral nerve stimulation. This had led to some denials based on an “experimental therapies” designation. Peripheral nerve stimulation is not experimental; it has been done for many years, and clinical evidence supports its use. It is important for the implanter to educate the medical director of the insurance company about this therapy.

Table 23-2 Description of Peripheral Nerve Neurostimulator

Setting

In many circumstances the neurostimulation procedure is not billable at an office location; these services are usually billed in a hospital or ambulatory surgery center facility setting. Some payers do allow the procedures to be performed in the office setting, with a payment differential provided to the physician providing the services. The amount of reimbursement based on the trial or permanent implant stage varies. The implanter and the staff should ensure that the insurance company understands both the setting and the equipment required to achieve the implant.

Facility Billing

Medicare Part B pays the facility fee to certified ambulatory surgical centers (ASCs) for services listed on the Medicare coverage list. Approximately 2400 surgical procedures are paid under “Groupers.” If multiple procedures are done at the same setting, expect a reduction of 50% for the additional service. The higher Grouper will be paid at 100%. “Add on” codes are usually reduced 50% as well, although some private payers only pay one facility fee, no matter how many levels the physician treats. The device would be billed separately by the facility or ASC. Hospital facility or Part A billing typically submits medical claims under revenue codes. As with an ASC, the devices are billed separately. The device codes used by CMS are listed in the Health Care Procedure Coding System (HCPCS), National Level II Medicare Codes book. It is important to remember that not all commercial carriers use this same coding system for the devices as Medicare uses. Checking with each carrier before billing for the devices regarding the codes they accept and pay is necessary. As with all procedure codes, check coding resource books each year for possible changes in either the code or code description.

Remember that facility and physician billing are very different. When a physician submits his claim with a single code for the lead or “array” (63650), the facility can submit the claims per electrode.

Common Errors in Billing

The most common billing errors made for these procedures is lack of supporting documentation to establish medical necessity and failure to predetermine if the insurance will cover the service.³ Costs are present at the time of implant and also going forward. There is typically a lifetime commitment to follow-up care, which includes analysis, reprogramming, and adjustments. Therefore it is imperative that each aspect of these procedures be addressed.

Authorization

Authorization staff must ask specific questions regarding approval to the patient’s insurer. General questioning increases the likelihood of error, including a retroactive denial of service or denial of payment from the carrier. All discussions with the insurer should be carefully documented, including, time, date, and names of representatives with whom the conversation has occurred. It may be helpful for the practice to develop an authorization checklist to ensure that all items have been discussed. On appropriate approval, the patient may then be scheduled for the procedure (Box 23-1).