95972 billing


Toledo, Ohio
Best answers
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..

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:
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.
Best answers
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.