Neurosurgery Coding Alert

Also, remember to document more conservative Tx attempts.

Neurostimulator electrode arrays are used when a clinician needs to deliver electrical stimulation to a specific part of the nervous system. The conditions that require array placement vary depending on where the electrodes are placed in the spinal epidural space, brain, peripheral nerves, or another target.

As a coder, you need to be able to spot the conditions that might call for neurostimulator electrode array placement and treatments the surgeon could try before opting for surgery — as well as coding correctly for array placement when the surgeon opts for the procedure.

Read on to learn more about coding for neurostimulator electrode array placements and their associated services.

Check out These Array Candidates

The following are conditions that may warrant a neurostimulator electrode array placement, but is not a comprehensive list:

• Chronic pain conditions have spinal cord stimulation, and the array is commonly used for persistent pain that has not responded adequately to conservative treatment. Diagnoses that may prompt an array placement include but are not limited to:
• G89.0 (Central pain syndrome)
• G89.21 (Chronic pain due to trauma)
• G89.4 (Chronic pain syndrome)
• M54.16 (Radiculopathy, lumbar region)
• M96.1 (Postlaminectomy syndrome, not elsewhere classified)
• Movement disorders have deep brain stimulation, and the surgeon uses implanted electrodes to modulate abnormal brain activity. Diagnoses that may prompt an array placement include but are not limited to:
• G20.A1 (Parkinson's disease without dyskinesia, without mention of fluctuations)
• G20.B1 (Parkinson's disease with dyskinesia, without mention of fluctuations)
• G24.9 (Dystonia, unspecified)
• G25.0 (Essential tremor)
• Drug-resistant epilepsy is another condition that uses responsive neurostimulation when seizures remain uncontrolled despite medication and the patient not being a suitable candidate for resection or ablation. The treating physician should document drug-resistant or intractable epilepsy. The exact epilepsy ICD-10-CM code depends on seizure type, etiology, and status epilepticus. Diagnoses that may prompt an array placement include but are not limited to:
• G40.011 (Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus)
• G40.019 (Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus)
• Bladder and bowel dysfunction often prompts sacral neuromodulation using an electrode near the sacral nerve roots. Focal peripheral nerve stimulation targets a specific nerve or nerve branch. This array might be necessary when a patient has a neurologic condition such as refractory obsessive-compulsive disorder, selected treatment-resistant psychiatric disorders, or other neurologic disorders.

Spot Tx Prior to Neurostimulator Implantation

Providers generally document trials of less invasive treatments before proceeding with permanent implantation. The exact requirements vary by payer, diagnosis, and device. Documentation should show what methods were previously attempted, how these methods were attempted for, and whether they helped.

There is not a required sequence and not every patient receives every service prior to neurostimulator implantation. However, the physician may try one of the following treatments before deciding to place a neurostimulator electrode array:

• Physical therapy (PT): The surgeon may order PT to improve strength, mobility, function, and pain control. This service is reported with a code from the 97161-97163 (Physical therapy evaluation: …) range.
• Medication management: The purpose of these visits would be medication management to treat neuropathic pain, inflammation, or other underlying pain mechanisms. You’ll choose a code from one of the following code sets for these visits:
• 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …)
• 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …)
• 99495-99496 (Transitional care management services with the following required elements: …)
• Epidural steroid injections: Providers recommend these shots to treat radicular pain, inflammation, or pain associated with spinal stenosis or post-laminectomy syndrome. You’ll report these injections with a code from 62321-62323 (Injection(s), of diagnostic or therapeutic substance(s) …).
• Diagnostic imaging: Providers perform these tests to identify the pain generator and rule out conditions requiring other treatment. Examples of codes you might use for diagnostic imaging include:
• 72141 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material)
• 72146 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material)
• 72148 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material).          

Check out This Clinical Decision for Implantation

For a spinal cord stimulator electrode array, the provider must decide whether the electrical stimulation is likely to improve the patient’s pain and function enough to justify an implanted device. The decision is cumulative based on diagnosis, pain characteristics, prior treatment response, and a temporary trial. Review this clinical example of a patient who is an electrode array placement candidate:

Patient: New 42-year-old patient with history of laminectomy and residual chronic pain

Chief complaint: Severe burning pain from lower back into my right leg for the past two years. “I cannot walk or sleep normally.”

Clinical findings:

• Lumbar and right-leg neuropathic pain, positive straight-leg raise, decreased sensation in the right L5 distribution, no progressive motor deficit
• MRI imaging demonstrates postoperative lumbar changes without a new surgical lesion requiring urgent intervention
• Radiculopathy, lumbar region
• Medication tried: Gabapentin, duloxetine, NSAIDs; with inadequate relief
• Candidate for neurostimulator electrode array placement

For this encounter, you would report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) for the evaluation and management (E/M) service with the following ICD-10-CM codes: M96.1 (Postlaminectomy syndrome, not elsewhere classified), M54.16 (Radiculopathy, lumbar region), and G89.4.

Note: Depending on whether the patient has an array placement, you may need to append modifier 57 (Decision for surgery) to 99204. Medicare requires modifier 57 for E/Ms that occur on the same day as surgery, while other payers might vary.

Check out This Clinical Neurostimulator Electrode Array Implantation

Here are details from an operative note for a patient undergoing a neurostimulator electrode array placement:

Patient: 68-year-old male

Chief complaint: Advanced Parkinson’s disease with disabling motor fluctuations and medication-induced dyskinesia

Clinical findings:

• 10-year history of Parkinson’s Disease
• Medication no longer helping the tremors
• Dyskinesias associated with levodopa therapy
• Underwent multidisciplinary DBS evaluation

Surgery:

Neurosurgeon utilizes stereotactic neuronavigational equipment for the head. Using this imaging to identify the target and create burr hole and places a right subthalamic nucleus electrode array. Places a left STN electrode array in the same operative session.

For this encounter, you would report:

• 61863 (Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array) for the first array
• +61864 (… each additional array (List separately in addition to primary procedure)) for the second array
• G20.B2 (Parkinson's disease with dyskinesia, with fluctuations) appended to 61863 and +61864 to represent the patient’s condition

Exception: If the operative report indicates that the encounter also included intraoperative microelectrode recording (MER), you will report 61867 (Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array) and +61868 (… each additional array (List separately in addition to primary procedure)) instead of 61863 and +61864.

Include Necessary Documentation

Coders need to ensure the record establishes the diagnosis and medical necessity for electrode array placement. Preoperative evaluation should demonstrate the decision making that led to surgery, including other evaluations, medication history, functional impairment, imaging, etc. A thorough operative report should clearly identify the procedure performed and the number of arrays implanted. Documentation should specifically identify intraoperative MER to bill the appropriate code, as shown in the examples above.

Kalie Bothma CPC, CEDC, CSAF, Contributing Writer