Spinal cord stimulator - Need help with billing

[AWHITACRE]

Need help with billing trial stimulator and permanent stimulator for Medicare. I am having so many problems with them being denied for duplicate. Does anyone have any good resources or information on billing?

Example 63685 - Insertion generator or receiver
63650- First lead
63650 - second lead (medicare denied for duplicate)

[rkmcoder]

(These are my opinions and should not be construed as being the final authority. Other opinions may vary.)

With the little bit of information that you have provided, it would seem that the proper coding of above example would be:

63685
63650
63650-59

If you have coded as above and are getting denials, then appeal with documentation.

Richard Mann, your pain management coder
rkmcoder@yahoo.com

[delphinus777]

Helpful pdf Guides on this site
http://professional-test.medtronic.c...ment/index.htm

COPIED THIS FROM THE CODING INSTITUE
3 Final Steps Assure Successful Spinal Neurostimulator Coding

Neurosurgery Coding Alert 2008: Volume 9, Number 10

Pay attention to frequency of programming services

If a surgeon moves forward with permanent placement of spinal neurostimulators, you will find yourself accessing many of the same codes you called upon to report the trial placement -- with a few wrinkles and additions. Read on for the rest of the story on error-free coding for spinal neurostimulators.

Heed Trial Placement

In Neurosurgery Coding Alert Vol. 9, No. 9, we learned that most candidates for spinal neurostimulation must undergo a trial to prove treatment efficacy, and that you would report the trial placement of the stimulating electrodes using either 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) or 63655 (Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural), as appropriate.

In addition, you may report the surgeon's effort for programming the temporary, external generator used to power and control the implanted catheter array or plate/paddle electrode(s), most often using 95972 (Electronic analysis of implanted neurostimulator pulse generator system [e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements]; complex spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour).

Permanent Placement Follows Trial

After a successful trial, you would report the surgeon's implanting of a long-term pulse generator for continued treatment. This may involve up to three steps, explains Mark Telles, senior manager of therapy access at Medtronic Neuromodulation.

1. First, the surgeon may disconnect the temporary pulse generator and remove the previously placed electrode(s), for which you should report 63660 (Revision or removal of spinal neurostimulator electrode percutaneous array[s] or plate/paddle[s]). Claim this code only once, regardless of the number of catheter arrays or plates/paddles the surgeon removes.

In addition, you should append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to show that the surgeon anticipated the procedure.

2. After a period of healing following removal of the previously placed electrodes, the surgeon will place a new catheter array(s) or plate(s)/paddle(s), as required. You will report these services using 63650 or 63655, as described previously ("One-Step-at-a-Time Ensures Successful Spinal Stimulation Claims," Neurosurgery Coding Alert, Vol. 9, No. 9, pages 65-67).

Once again, you should append modifier 58 to denote a staged service that occurs during the global period of an earlier procedure.

3. Finally, the surgeon will implant the long-term pulse generator, for which you would report 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling) with modifier 58.

"The implant occurs via a separate incision, usually either in the belly or the buttocks just below the waistline," Telles explains. "The surgeon then connects the leads to the generator by tunneling the wires under the skin."

Example: The surgeon places a catheter electrode array for trial neurostimulation. The patient returns four days later and reports positive results. The surgeon disconnects the external neurostimulator and removes the trial electrode. Two weeks later, the patient returns for placement of a new electrode array and implantation of the long-term generator. You would report:

63650 for the trial electrode placement
63660-58 for removal of the trial electrode at the second visit
63650-58 for placement of the long-term electrode array at the final visit
63685-58 for implanting the pulse generator at the final visit.
Watch for: Occasionally, the surgeon will attach the long-term pulse generator to the previously placed electrodes. In other words, he will not replace the catheter arrays or plate/paddle electrode(s) used during the trial period. When this occurs, you would report 63685 for inserting the pulse generator, in addition to initial placement of the electrodes (63650) only.

Example: The surgeon places the electrode array and tests the patient "on the table" for response to the stimulation. The patient shows benefit and the surgeon immediately implants the long-term generator, attaching it to the same leads he used for the trial.

You would report 63650 and 63685. Because the entire procedure occurs on the same date of service, you will not need modifier 58.

Seize Programming Opportunities

After the surgeon has placed the permanent pulse generator, you will have additional opportunities to bill for programming services.

Remember: Most modern neurostimulators qualify as "complex," as defined by CPT, and therefore you would report 95972 for the first hour of programming, Telles says. In the unusual event that the surgeon would require longer than an hour for programming, you may report +95973 (...complex spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative subsequent programming, each additional 30 minutes) to describe each additional 30 minutes.

In the equally unlikely event that the surgeon programs a "simple" (as defined by CPT) neurostimulator, you would skip 95972/95973 in favor of 95971 (...simple spinal cord, or peripheral [i.e., peripheral nerve, autonomic nerve, neuromuscular] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming).

Important: You should choose a programming code based on the number of parameters the pulse generator is capable of affecting, not the number of parameters the surgeon alters, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, with MJH Consulting in Denver.

Finally, you may call on 95970 (Electronic analysis of implanted neurostimulator pulse generator system [e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements]; simple or complex brain, spinal cord, or peripheral neurostimulator pulse generator without reprogramming) for "interrogation of the neurostimulator battery," Telles explains.

In other words, you may call on 95970 "to describe analysis of an implanted neurostimulator pulse generator without reprogramming," according to CPT Assistant (Sept. 2005).

Observe frequency limitations: The surgeon may have to adjust the neurostimulator parameters (such as pulse frequency, duration, and amplitude, among others) over time to provide the patient with maximum benefit. Although you may bill for these ongoing programming sessions, most payers will not consider programming necessary more often than once every 30 days.

Don't Forget Follow-Ups

If the surgeon removes or revises the neurostimulator leads at a future date, you may once again report 63660.

Should the surgeon revise or remove a previously implanted pulse generator, you should select 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver).

Watch for immediate replacement: If the surgeon removes and immediately replaces the pulse generator, however (such as for a battery change), you should report 63685 rather than 63688.

You would not need a modifier in any of these cases, unless the removal or revision occurred during the global period of a previous procedure.

[AWHITACRE]

Thank you so much for the information

[Ketti]

What is the global period for a spinal cord stimulator? I just had an office visit that was denied because it is still in the global period, but it has been 3mos since the procedure. Thanks so much!

[lodawnyoung]

It depends on the procedure performed. If it was a percutaneous implantation it is a 10 day global; however, if a laminectomy for implantation was performed then it is a 90 day global.

[vreyes@axismb.com]

we have encounter several of denials for Medical Necesity CO-50 on Spinal Cord Stimulator procedures the trial nor for the permanent date of services.
we have verified all documents, LCD, DX code, etc.

billing method we use for the SCS procedure are as follow:

SCS Trials
63650
63650-50

SCS Permanent
63685
63650
63650-59

please indicate what is been done incorrectly so we can start obtain payments.

[rmelissa]

I'm glad there is a discussion about this. I ran across an AMA CPT Assistant Reference, August 2010 that addresses the issue of billing for the removal of trial leads with permanent leads.

"The guidelines also indicate that CPT codes 63661 or 63663 should not be reported when removing or replacing a temporary percutaneously placed array for an external generator. The replacement of a temporary placed array(s) with a permanent array or paddle is included in the insertion procedure and is not separately reportable. If the temporary array is removed without permanent placement, it is a subsequent Evaluation and Management (E/M) service, which is typically within the global period of the initial placement and therefore not reported."

"If, during the trial period, a level of pain relief has not been achieved, or the patient elects not to continue with neurostimulator treatment, removal of the percutaneous (externalized) neurostimulator electrode is performed.
The work of removal is not reportable, since removal is inherent in the original percutaneous electrode placement code 63650. If it is determined that successful pain relief has been attained, a decision may be made to place a permanent electrode array via a percutaneous epidural needle, laminotomy or laminectomy."

This could explain why there are denials for duplicate work on different dates of service. I'm not completely sure that adding mod 58 would be appropriate. It would certainly bypass the global period for the paddle leads (90 days) but it still doesn't mean that you should. Or maybe the CPT assistant reference is incorrect? I'd love your thoughts on this.