Wiki 95971/95972 To Bill Or Not To Bill???


Greenfield Twp, PA
Best answers
Ok fellow coders, I have a situation and would love some opinions and if possible backed up with AMA, CPT, or CMS direction.

Patient comes in with an implanted spinal cord stimulator for analysis and possible reprogramming. I have been told that the Medtronic reps do the actual performance of these codes with the physician in the room. My opinion is we should not be billing for the programming. What do you think?
Thanks for any input!
"From a CPT coding perspective, based on the information available in your inquiry, and in answer to your question, CPT is a set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers, therefore, it would not be appropriate to report this code if performed by a manufacturer's representative."
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Above is a part of response I received from the AMA CPT Network in regards to 95971/95972 from November 2010.

Below is from the Medtronics PDF for Spinal Cord Stimulation

Analysis/ Programming
Note: In the office, analysis and programming may be furnished by a physician, practitioner
with an “incident to” benefit, or auxiliary personnel under the direct supervision of the
physician (or other practitioner), with or without support from a manufacturer's representative. The patient or payer should not be billed for services rendered
solely by the manufacturer's representative. Contact your local carrier or payer for interpretation of applicable policies.

Below is from the Boston Scientific PDF for Spinal Cord Stimulation

A physician should not bill if the service is performed entirely by, or under the direction of, a manufacturer representative without payer consent. If the service is performed in part by a physician or physician-supervised personnel (in accordance with the Medicare incident to requirements) and in part by a manufacturer representative, the physician should contact the payer and/or a reimbursement consultant before billing the service
any updated info?

I've been told by one of our pain providers to bill for a programming performed by the manufacture's rep under his direction. I've never billed a programming performed by the manufacturer's rep in the past and I don't believe it should be billed when performed by the rep. When I googled this I found two older directives from Medtonic and Boston Scientific. Both says it shouldn't billed by the provider when any part of it has been performed by the manufacturer's rep. Does anyone know if there has been any updates in the past couple of years? This time the manufacturer is Bioness.