Match Diagnosis With Neurostim Codes--and Avoid Denials
Published on Thu Oct 26, 2006
Don't risk losing allowable reimbursement
If your neurologist uses neurostimulation to treat patients- chronic pain, confirm that your patients meet their carriers- medical-necessity requirements before performing the procedures.
Many carriers still consider neurostimulation to be investigational for some diagnoses, so get your carriers- policies in writing and keep an ABN (advance beneficiary notice) nearby just in case. Categorize Diagnoses to Prove Medical Necessity Just because neurostimulation (also known as spinal cord stimulation, or SCS) might improve the patient's chronic pain doesn't guarantee easy coding or assured reimbursement.
Many carriers classify diagnoses as -medically appropriate,- -medically necessary- or -investigational.- Knowing which category the patient's condition falls into can help your coding efforts.
Check documentation: Before coding neurostimulation procedures, verify that you have documentation of previous treatments to prove to the carrier that your physician tried other treatment methods--but they were ineffective. This documentation helps show that the patient needs neurostimulation treatment as the last effort to relieve his pain, says Darlene Isom, a billing supervisor at Northwestern Medical Faculty Foundation Inc. (NMFF) in Chicago.
Always check the carrier's SCS policy for neurostimulation because the payer might have a short list of conditions justifying treatment. Example: Common conditions that support medical necessity for neurostimulation include:
- Radiculopathies (diseases involving the nerve roots, including failed back surgery syndrome, arachnoidis and epidural fibrosis)--many diagnoses fall under this umbrella, including codes 729.2 (Neuralgia, neuritis, and radiculitis, unspecified) and 322.9 (Meningitis, unspecified).
- Reflex sympathetic dystrophy (also known as complex regional pain syndrome type 1)--select the appropriate code from 337.20-337.29 (various sites for Reflex sympathetic dystrophy).
- Intractable pain from severe peripheral vascular disease (PVD)--code the patient's type of pain first, with the PVD as a secondary condition (443.9, Peripheral vascular disease, unspecified; 747.64, Other anomalies of peripheral vascular system; lower limb vessel anomaly; or 747.69, Anomalies of other specified sites of peripheral vascular system). Even if the carrier's policy includes the patient's condition on its list of approved diagnoses, Isom still recommends obtaining certification before scheduling the procedure. Cover Your Bases With an ABN If, on the other hand, the carrier considers the stimulator placement investigational, ask the patient to sign an ABN before scheduling the procedure, Isom says. Some carriers consider neurostimulator use as investigational for conditions such as:
- Intractable angina--413.9 (Other and unspecified angina pectoris)
- Plexus lesions caused by trauma or malignancy--353.0-353.9 (various locations of nerve root or plexus lesions or disorders), 722.x series (Intervertebral disc disorders), 720.x (Ankylosing spondylitis and other inflammatory spondylopathies), 721.x (Spondylosis and allied disorders), 723.x (Other disorders of cervical region) or 724.x (Other and unspecified disorders of back)
- Multiple sclerosis--340 (Multiple sclerosis)
- Neuropathy due to injuries, surgery, entrapment or scars--codes such as 355.9 (Mononeuritis of unspecified site)
- Postamputation pain--353.6 (Phantom limb [syndrome])
- Postherpetic neuralgia--053.12 (Postherpetic [...]
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