Urology Coding Alert

Thanks to CMS'national coverage determination for sacral nerve stimulation (SNS), there's no reason you should be receiving denials for your SNS claims unless you're not coding according to the latest guidelines. SNS is a procedure that uses implanted devices to stimulate the sacral nerves, which in turn causes bladder muscle contraction. SNS is used for patients with loss of bladder function control that results in one of the following indications: urge incontinence (ICD-9 788.31), urinary urgency-frequency syndrome (ICD-9 788.41) and urinary retention (788.20), says Denise Littrell, coding specialist for Urology of Indiana in Indianapolis. 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. However, not just any patient with urge incontinence, urinary urgency-frequency syndrome and/or urinary retention is a candidate for SNS treatment. 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 be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. The following patients are excluded: those with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications. Patient must have had a successful test stimulation in order to support subsequent implantation. Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated." Stimulate Temporary SNS Reimbursements With 64561 After exhausting conventional therapies, urologists must first "implant a temporary lead to confirm that the patient gets feeling from the leads," Littrell says. According to the national coverage determination (NCD), this preliminary test, 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 leads, use 64561 (Percutaneous implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]).

"Typically, two temporary leads are placed 'bilaterally'to test whether one side is more effective than another and a prime location for the permanent lead," Littrell says. But don't use the bilateral modifier, -50, to indicate that the leads were placed bilaterally, she instructs coders. Though the leads are referred to as "bilateral," they are actually on both sides of the spinal cord.

"Code the first temporary lead with 64561 and each additional temporary lead with 64561-50, each on a separate line." Don't be surprised if a third lead is placed in addition to the bilateral leads for testing [...]