New Guidelines Mean Broader Application of Deep Brain Stimulation Codes
Published on Tue Jul 01, 2003
New CMS guidelines allow for broader use of deep brain stimulation (DBS) for treatment of essential tremor (ET) and Parkinsons disease. When applying DBS, surgeons must be careful to report all portions of the service (including incision, placement and, in some cases, programming; see Dont Forget to Charge for Programming ) while supplying an appropriate diagnosis and meeting other submission requirements. Document the Appropriate Conditions DBS refers to high-frequency electrical stimulation of anatomic regions deep within the brain using surgically implanted electrodes. The surgeon may place the electrodes on one (unilateral) or both (bilateral) sides of the brain at one of three locations: the thalamic ventralis intermedius nucleus (VIM), subthalamic nucleus (STN) and globus pallidus interna (GPi).
Beginning April 1, CMS program memorandum, transmittal AB-03-023 (change request 2553), instructs carriers to pay for (previously uncovered) unilateral or bilateral VIM DBS for the treatment of ET and/or Parkinsonian tremor and unilateral or bilateral STN or GPi DBS for the treatment of Parkinsons disease. The memo specifies that all DBS units must meet with U.S. Food and Drug Administration approval and outlines the following conditions for coverage:
For thalamic VIM DBS:
The patient must have a diagnosis of essential tremor based on postural or kinetic tremors of hand(s) without other neurologic signs, or a diagnosis of idiopathic Parkinsons disease (exhibiting at least two cardinal features of Parkinsons, such as tremor, rigidity or bradykinesia) of a tremor-dominant form.
Marked disabling tremor of at least level three or four on the Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or equivalent scale) in the extremity intended for treatment, causing significant limitation in daily activities despite optimal medical therapy. For STN or GPi DBS:
A diagnosis of Parkinsons disease based on the presence of at least two cardinal features of Parkinsons (tremor, rigidity or bradykinesia).
Presence of advanced idiopathic Parkinsons as determined by the use of Hoehn and Yahr stage or Unified Parkinsons Disease Rating Scale (UPDRS) part III motor subscale.
The patient is L-dopa responsive with clearly defined on periods.
The patient must exhibit persistent disabling Parkinsons symptoms or drug side effects (for example, dyskinesias, motor fluctuations or disabling off periods) despite optimal medical therapy.
In all cases, the patient must be willing and able to cooperate during a conscious operative procedure, as well as during postsurgical evaluations, adjustments of medications, and stimulator settings.
Documenting that you have met these requirements is essential, says Jennifer Schmutz, CPC, of Neurosurgical Association in Salt Lake City. Regarding DBS, the hardest part has been getting the insurances to authorize the procedure, she says. Once that has been done, we havent had problems receiving payment. But to get an authorization, I have to prove that medications, therapy and other options have been tried. Watch for [...]
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