95972 billing

lcole7465

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So, I have been getting denials for 95972 when billed with SCS implant. I've tried billing this with modifier -51 or -59 with no luck. The insurances keep denying as inclusive, I'm thinking there maybe needs to be more detailed documentation for the post-operative programming in order to bill this correctly. Below is a snippet of the op report. Any input would be greatly appreciated..

Operation:
1.Spinal cord stimulator implant.with placement of octad electrodes x2.
2.Placement of a pulse generator.
3.Examination under fluoroscopy.
4. Intraoperative and postoperative programming, complex.
Details of Procedure:
PROCEDURE:
Then a 10-blade scalpel was used to incise the skin. Then sharp and blunt dissection was done down to the prevertebral fascia using electrocautery for hemostasis. Once the prevertebral fascia was encountered, there were two 15-gauge Tuohy needles that were used to advance into the epidural space using loss of resistance to air and using fluoroscopic guidance to place the needle tips in the AP and lateral views. Once the epidural space was entered, there was advancement of the 2 electrodes under live fluoroscopy to the intervertebral space at T8-9. The electrodes were then connected and programmed to cover the patient's painful areas, which were functioning appropriately. The needles and stylets from the leads were then removed with confirmation of no lead migration using fluoroscopy. Then 2 anchors were advanced over the electrodes and secured to the electrodes using the torque wrench provided by manufacturer and then they were secured to the prevertebral fascia using 3-0 silk sutures on each anchor.

Then a planned left lateral pocket site was created for the pulse generator. Another 10 mL of 1% lidocaine plus 0.5% bupivacaine was injected through a 27-gauge needle in approximately a 6-cm long planned incision in the subcutaneous skin and also deep to the skin. The skin was incised with a 10-blade. Then sharp and blunt dissection was performed with electrocautery for hemostasis to create a pocket approximately the size of pulse generator, approximately 1-inch deep to the skin. The pocket was then connected to the mid-line incision using a tunneler provided by manufacturer. The permanent leads were then tunneled through to the pocket, to the generator site, connected to the generator with confirmation, and the entire system was working. The permanent leads were then secured to the generator using the torque wrench provided by Boston Scientific and both pockets were then irrigated with bacitracin solution. Care was taken to ensure that there was hemostasis, which was adequate. Then there was closure of both pockets with interrupted 2-0 Vicryl, followed by continuous running 3-0 Vicryl, followed by 3-0 Novafil at the skin.

The impedance were then also confirmed to be functioning appropriately and the system was functioning entirely after closure of the pockets. The skin was washed and dried with wet-to-dry and then covered with bacitracin ointment, covered with Covaderm dressing. The patient was placed in the supine position with an abdominal binder and taken to the recovery room for postoperative programming.
 
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My guess is the payer is assuming it is part of the implant procedure. From the CPT manual:

Test stimulation to confirm correct target site placement of the electrode array(s) and/or to confirm the functional status of the system is inherent to placement, and is not separately reported as electronic analysis or programming of the neurostimulator system.
 

lcole7465

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It is a column 2 edit per NCCI as of 2019
I have tried billing with modifier "XU" and I'm still getting denials even on the appeals. I have had the provider add the programming parameters to the notes. I'm at a loss on this one. I can see it not getting paid on the trial, but it's even getting denied on the permanent implants.
 

SharonCollachi

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I'm get that it's not billable/payable for the trial, but for the permanent implant, he does complex programming of the implant.
That didn't answer my question. Why do you think it should be paid when the CCI edits say its already included for reimbursement? That the RVUs are already calculated to include that work, since it always has to be done? Just because it's not paid separately doesn't mean it's not paid.

How much work is he doing vs. how much work is the implant rep doing?
 

dwaldman

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"Programming codes 95971 and 95972 also may not be assigned to represent test stimulation during the implantation procedure, and NCCI edits do not permit programming codes 95971 and 95972 to be coded separately with lead or generator implantation. However, an override is permitted in the context of actual programming performed at the time of lead or generator implantation."


Above is from the Medtronics reimbursement guide for Spinal Cord Stimulation
_____________________________


1. Don't Boston Scientific reps typically used a device that they bring with them to do the programming and technically the rep is performing the programming. Does the physician have training to utilize their equipment and is there anything to support he personally using their equipment to perform the programming, if not and the rep actually doing this under his supervision, he can not bill as personally performing under the incident to benefit as it only applies to someone that is his employee working under his direction is my understanding. Additionally, from the AMA performed does not mean standing there why the rep provides a service that free of charge to insurance when the rep perfoms. I don't know the circumstance and he might choose to do his own programming, but I think it is the most important take away when discussing this service. This is also mentioned in AMA CPT Assistant Feb 2019:

"Editorial revisions were also made to existing codes 95971 and 95972 to clarify that these codes should be used to report the electronic analysis and programming of spinal cord or peripheral nerve (eg, sacral nerve) neurostimulators, and specifies that these services are performed by a physician or other qualified health care professional (QHP). "

2, The operative note provided does not support CPT 95972. CPT 95972 requires more than 3 parameters that might be in separate note but the note that is provided does not describe the physician documenting he personally programmed more than 3 parameters.

AMA CPT Assistant Feb 2019
For purposes of counting the number of parameters being programmed, a single parameter that is adjusted two or more times during a programming session counts as one parameter. Simple and complex programming are defined as follows: • Simple programming of a neurostimulator pulse generator/transmitter includes adjustment of one to three parameter(s). • Complex programming includes adjustment of more than three parameters.

3. From AMA CPT Assistant April 2011, temporary lead placement./trial can be billed with programming and they do not describe it as being inherent to the trial although I agree that there has been other entities saying they believe it is inherent, I believe at one time the AANS global surgery package guide stated it was included in the trial is what a Medtronic rep told me:

"Question 3: May code 95972 be reported for complex programming of an external nonimplanted neurostimulator pulse generator that is attached to a temporary electrode array?

AMA Response: Correct choice of programming codes is not based upon the intent of the stimulator lead array being used as a “temporary” external lead or as a “ permanent” implanted lead. An inherent portion of the lead placement, and is not additionally reported using either code 95971 or 95972, is electronic analysis during a percutaneous electrode array placement (63650) or during a laminectomy for implantation of a plate/paddle electrode array (63655) when only impedance testing and stimulation is performed to verify function of the leads (not the pulse generator). "
 
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