Introduction

Appropriate documentation and coding for neurostimulation procedures are not only imperative for maintaining a proper record, but, if they are done incorrectly, they can expose the practice to financial and legal liability risk.¹ Because of regionally diverse payer- and carrier-related issues, this chapter presents an overview of coding and billing topics. It is also important to note that regulations pertaining to coding and billing changes are updated routinely; all readers are strongly encouraged to refer to their local carrier policies for the latest information. Although local policies are prone to change, proper documentation as a measure of practice health and stability remains a staple of practice management that demands daily attention.

Proper Documentation and Medical Necessity

Medical necessity should be documented in the office notes or operative preamble. This documentation should include the disease state, pain characteristics, functional limitations, and degree of suffering. Additional documentation should include failed treatments such as physical therapy, medications, injections, and previous surgical efforts. Any current options should be addressed, and a decision to move forward with the device should be noted. The surgical documentation should not only represent justification for necessity, but should contain complete, concise data that support what the practitioner billed and why. An example of this documentation would be, “Before this spinal cord trial the patient underwent medical management with oral medications from different classes (list classes), injections (list injections), physical medicine, and other (list other options). The patient had no acceptable surgical options and wished to move forward. Informed consent was obtained, and the patient was taken to the procedure area.”

Spinal Cord Stimulation

The proper current procedural technology (CPT) coding for the trial and permanent stimulator procedures is listed in Table 23-1.² All patients must meet clinical criteria, and medical necessity should be documented extensively in the patient record. Note that billing for removal of the trial percutaneous leads is not appropriate if no surgical incision and no surgical anchoring were performed in the initial placement. These codes were created specifically for trial leads that were placed using the “cut-down” technique. The global period for the listed surgical codes is 10 days. Wound checks and physical examinations are not typically billable for the first 10 days after placement of the spinal cord stimulation (SCS) system.

Table 23-1 Neurostimulator Current Procedural Technology Codes

63650	Percutaneous implantation of neurostimulator electrode array, epidural
63655	Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
63661	Removal of spinal neurostimulator electrode; percutaneous array, including fluoroscopy when performed
63662	Removal of spinal neurostimulator electrode; plate/paddle, placed via laminotomy or laminectomy, including fluoroscopy when performed
63663	Revision, including replacement when performed, of spinal neurostimulator electrode percutaneous array, including fluoroscopy when performed
63664	Revision, including replacement when performed, of spinal neurostimulator electrode plate/paddle placed via laminotomy or laminectomy, including fluoroscopy when performed
63685	Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
63688	Revision or removal of implanted spinal neurostimulator pulse generator or receiver
Analysis-Programming Codes
95971	Electronic analysis of implanted neurostimulator pulse generator system (rate, pulse amplitude and duration, configuration of waveform, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements[s]); simple spinal cord or peripheral (peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming
95972	Electronic analysis of implanted neurostimulator pulse generator system (rate, pulse amplitude and duration, configuration of waveform, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements[s]); complex spinal cord or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour
+95973	Electronic analysis of implanted neurostimulator pulse generator system (rate, pulse amplitude and duration, configuration of waveform, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements[s]); complex spinal cord or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (list separately in addition to the code for the primary procedure)
If no reprogramming is done, see procedure code 95970.
Modifier Possibilities (But Not Limited to):
58	Staged or related procedure or service by the same physician during the postoperative period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was: (a) planned prospectively at the time of the original procedure (staged); (b) more extensive than the original procedure; or (c) for therapy following a diagnostic surgical procedure.
59	Distinct procedural service: Under certain circumstances the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances.
51	Multiple procedures: When multiple procedures other than Evaluation and Management services are performed at the same session by the same provider, the primary procedure or services may be reported as listed. The additional procedure(s) may be identified by appending modifier 51 to the additional procedure or services code(s).