Parkinson’s and Deep Brain Neurostimulator Coding in CPT

If any disease will cause you to slow down and appreciate life, it’s Parkinson’s disease. In this article, you will learn about the disease, its treatment, when deep brain neurostimulation is performed, and and how to assign the correct CPT codes for two coding exercises using codes 95970, 95983, and 95984.

Parkinson’s and Deep Brain Neurostimulator Coding in CPT

Parkinson’s Disease

When a loved one is diagnosed with Parkinson’s disease (PD), it can have a ripple effect, causing great distress to not only the suffering individual but to his or her family and friends as well. Parkinson’s disease is a chronic, progressive disorder of the nervous system that mainly affects movement. Although there is no cure, treatments are available to improve its symptoms. One of the treatments performed is deep brain stimulation.

According to the Parkinson’s Foundation:

  • Approximately 60,000 Americans are diagnosed with Parkinson’s disease each year.
  • Nearly one million people will be living with Parkinson’s disease (PD) in the U.S. by 2020, which is more than the combined number of people diagnosed with multiple sclerosis, muscular dystrophy, and Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis).
  • Men are 1.5 times more likely to have Parkinson’s disease than women.

Symptoms

Parkinson’s disease is called a movement disorder because the most obvious symptoms are the motor symptoms. However, PD impacts many body systems, and the symptoms and progression of the disease are highly individual. In other words, what one person experiences is not necessarily what another person will experience.

Motor Symptoms

The main motor symptoms of PD are:

  • Bradykinesia: slowness of movement
  • Tremor: involuntary shaking in the hands, arms, legs, jaw, or tongue
  • Rigidity: stiffness or tightness in the arms, legs, or trunk

Postural instability is another motor symptom that involves imbalance and falls, but it does not tend to happen until later in the disease. If postural instability does occur early in the disease, it is often a sign of atypical parkinsonism.

In order to be diagnosed with PD, a patient must have bradykinesia plus tremor or rigidity.

Other motion symptoms include:

  • Cramping (dystonia): repetitive or sustained involuntary muscle twisting or tightening
  • Drooling (sialorrhea): excessive saliva or drooling that may result from a reduction in automatic actions such as swallowing
  • Dyskinesia: involuntary, erratic movements of the face, arms, legs, or trunk
  • Festination: short, quick steps during walking that may lead to increased falling and is often seen in combination with freezing
  • Freezing: temporary and involuntary inability to take a step or initiate movement
  • Masked face (hypomimia): decreased facial expression due to bradykinesia and rigidity
  • Micrographia: small, disorganized, and crowded handwriting due to slowness of movement
  • Shuffling gait: in combination with short steps and often poor posture
  • Soft speech (hypophonia): soft and even hoarse voice at times

Non-Motor Symptoms

Non-motor symptoms can be more disabling than motor symptoms and may include:

  • Cognitive changes: problems with attention, planning, language, memory, or dementia
  • Constipation
  • Early satiety: feeling full after eating small amounts
  • Excessive sweating: when medications are wearing off
  • Fatigue
  • Increase in dandruff (seborrheic dermatitis)
  • Hallucinations and delusions
  • Lightheadedness (orthostatic hypotension): blood pressure drops when standing
  • Loss of sense of smell or taste
  • Mood disorders such as depression, anxiety, apathy, and irritability
  • Pain
  • Sexual problems such as erectile dysfunction
  • Sleep disorders such as insomnia or REM sleep behavior disorder (RBD)
  • Urinary urgency, frequency, and incontinence
  • Vision problems, especially when reading up close
  • Weight loss

Some of the above symptoms, such as loss of smell, constipation, depression, and REM sleep behavior disorder, may occur years before PD is diagnosed.

Stages of Parkinson’s Disease

According to the Parkinson’s Foundation, there are five stages of Parkinson’s disease, each with their own set of symptoms. Although these stages indicate the typical patterns of progression, it does not necessarily apply to every individual with PD. This is because some people may go through these stages in a different order or with a different intensity.

Stage 1: Mild symptoms occur that do not typically interfere with daily life. Tremor and other movement symptoms take place only on one side of the body, and changes in posture, walking, and facial expressions start to happen.

Stage 2: Symptoms get worse. Tremor, rigidity, and other movement symptoms affect both sides of the body. Walking and posture problems may be noticeable. Daily tasks are more difficult and are taking longer to accomplish, but the patient can still live alone.

Stage 3: This is referred to as mid-stage. Loss of balance and slowness of movements are distinguishing characteristics, and falls are more prevalent. Symptoms greatly diminish activities, such as dressing and eating, but the patient is still entirely independent.

Stage 4: Symptoms are severe and restricting. Standing can be done without assistance, but a walker may be needed to get around. The person is unable to live alone and needs help with activities of daily living.

Stage 5: This is the most advanced and crippling stage. Standing or walking is almost impossible due to stiffness in the legs. Either a wheelchair is needed, or the patient is bedridden. The patient may also experience hallucinations and delusions. Nursing care is needed around the clock for all activities. In addition to these motor symptoms, there are a significant number of non-motor symptoms experienced by the patient.

Causes

Scientists are not certain what causes PD, but they believe genetics and the environment are to blame. To what extent each is involved varies from person to person, but what is known is that all PD patients show a loss of dopamine in the brain as well as symptoms and disease progression unique to them. Parkinson’s is rarely hereditary.

Diagnosis

According to the Parkinson’s Foundation, there is currently no specific blood test or imaging scan available to diagnose Parkinson’s disease. Instead, a neurologist will diagnose PD based on: 

  • A detailed history of symptoms, health problems, and medications (past and present). Some medical conditions and medications can cause symptoms that resemble Parkinson’s disease.
  • A detailed neurological examination by a neurologist to assess movement of arms and legs, muscle tone, gait, and balance while the patient performs certain tasks. This exam is performed to look for:
    • Animation in expression and speech
    • Tremor in extremities at rest or in action
    • Stiffness in extremities or neck
    • Maintained balance and examination of posture
  • A Unified Parkinson’s Disease Rating Scale (UPDRS) is used by a neurologist and movement disorder specialists to document and assess the exam of a PD patient at baseline, determine the effectiveness of medication, and track the disease progress over future visits.
  • Most people with PD respond well to dopaminergic medications. For those who do not, an alternative diagnosis may be made, such as atypical parkinsonism. The physician may also perform additional tests, including an MRI of the brain.
  • When a neurologist is unsure of a PD diagnosis, patients are typically referred to a movement disorder specialist and DaTscans are ordered. A DaTscan is a brain imaging test that uses a radioactive drug to help determine the amount of dopamine in the patient’s brain. Although a DaTscan cannot diagnose PD, it can confirm it. If the patient’s history and exam point to Parkinson’s and the patient meets the diagnostic criteria, a DaTscan is not necessary.

Parkinsonism (atypical Parkinson’s disease or Parkinson’s plus) is a term used to describe the signs and symptoms found in Parkinson’s disease (slowness, stiffness, tremor, and imbalance). However, there are other conditions that may have one or more of these symptoms and look like Parkinson’s. They include: 

  • Essential Tremor
  • Normal Pressure Hydrocephalus
  • Dementia with Lewy Bodies
  • Multiple System Atrophy
  • Corticobasal Syndrome
  • Progressive Supranuclear

Palsy Parkinson’s disease (idiopathic Parkinson’s) is the most common form of Parkinsonism. People with PD have a higher chance of developing other diseases, such as diabetes, melanoma (skin cancer), osteoarthritis, gastrointestinal diseases, genitourinary dysfunction, and cardiovascular disease. Many people with PD also have a vitamin D deficiency.

Treatment Options

Treatment is based on the individual’s symptoms and includes such options as medication, surgery, and lifestyle changes.

Medications

There are several different medications, but none of them have the ability to reverse the effects of Parkinson’s. Instead, the individual motor symptoms of PD are treated with a specific medication or combination of medications and will need to be adjusted as time goes on and the disease progresses. Other variables considered when prescribing the medication are the patient’s age, other health issues, and the medications being taken to treat them.

According to the Michael J. Fox Foundation for Parkinson’s Research, and WebMD, the following medications mainly affect tremor, stiffness, and slowness:

  • Dopamine Replacement Therapy. Levodopa/carbidopa is the most effective and most commonly prescribed drug for PD.
  • Dopamine agonists imitate the effect of dopamine in the brain.
  • Monoamine Oxidase B (MAO-B) Inhibitors reduce the normal activity of an enzyme called monoamine oxidase.
  • Catechol-O-methyltransferase (COMT) Inhibitors are only used in conjunction with levodopa and prevents levodopa from breaking down outside of the brain.
  • Anticholinergic medications reduce acetylcholine, a brain chemical, which restores the already reduced balance caused by PD of this neurotransmitter and dopamine.
  • Amantadine is often used in early and mild Parkinson’s to reduce motor symptoms.

Medications also exist for non-motor symptoms of PD, but they are not part of the more widely-known motor symptoms that are characteristic of the disease.

Surgery

There are two surgical options available for PD patients, which include Deep Brain Stimulation (DBS) and Insertion of L-Dopa Therapy.

Parkinson’s and Deep Brain Neurostimulator Coding in CPT

Deep Brain Stimulation (DBS) 

Deep Brain Stimulation (DBS) is a device that is surgically implanted in the patient to reduce the motor symptoms of PD. This surgery tends to improve the symptoms that had previously responded to medication like levodopa. Electrical pulses are delivered to the brain to block symptoms of tremor, slowness of movement, and stiffness and inflexibility of the legs, arms, neck, and trunk.

Deep brain stimulation is something to consider when a patient has had PD for four or more years and has had a lot of “off” episodes, when the medications are not working well, or when there are uncontrolled, abnormal movements. The benefits of DBS are that the patient can reduce the medications, the motor symptoms will be greatly reduced, and there will be fewer side-effects from the medications since they are being reduced.

According to Healthline, a DBS consists of three parts:

  • A battery-operated pulse generator (neurostimulator) implanted in the chest
  • Electrodes implanted in particular movement centers of the brain
  • Insulated wires (leads) that carry electric pulses from the generator to the electrodes

Deep brain stimulation is something to consider when a patient has had PD for four or more years and has had a lot of “off” episodes, when the medications are not working well, or when there are uncontrolled, abnormal movements. The benefits of DBS are that the patient can reduce the medications, the motor symptoms will be greatly reduced, and there will be fewer side-effects from the medications since they are being reduced.

Insertion of L-Dopa Therapy

L-Dopa therapy is a surgical procedure performed to insert a tube in the small intestine so that a suspended form of carbidopa and levodopa can be delivered continuously by a pump. According to Duopa, the pump delivers medication for up to 16 hours.

Below is a two-minute video on the 3 stages of deep brain stimulation surgery.

CPT Coding

Let’s consider these coding exercises.

Coding Exercise #1

A 62-year-old patient with Parkinson’s disease had a deep brain neurostimulator inserted three weeks ago to fight tremors from Parkinson’s disease. He is still experiencing some tremor and presents today for a generator check without programming.

CPT: 95970

The documentation states that the provider tested the implanted brain neurostimulator pulse generator. A generator check is an analysis of the device to ensure it is working properly. No programming was done.

Locate and Verify

In the CPT Index, we can look under Analysis/implant/neurostimulator pulse generator, 95970-95984. In the Tabular listing, we can verify the correct code as:

95970, Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming.

CPT code 95970 describes a subsequent electronic analysis of a previously implanted generator and should not be reported at the time of insertion of the generator.

CPT code 95970 can be found in the Medicine section of the CPT coding manual under Neurology and Neuromuscular Procedures/Neurostimulators, Analysis-Programming Procedures (95970, 97971, 95972, 95976, 95977, 95983, 95984).

According to the CPT coding guidelines:

  • CPT code 95970 should not be reported with the following codes during the same operative session: 43647, 43648, 43881, 43882, 61850, 61860, 61863, 61864, 61867, 61868, 61880, 61885, 61886, 61888, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 64553, 64555, 64561, 64566, 64568, 64569, 64570, 64575, 64580, 64581, 64585, 64590, and 64595.
  • CPT code 95970 should not be reported in conjunction with 95971, 95972, 95976, 95977, 95983, and 95984.
  • Codes 95971 and 95972 involve electronic analysis with simple or complex programming of the neurostimulator pulse generator/transmitter implanted in the spinal cord or peripheral nerve.
  • Codes 95976 and 95977 involve electronic analysis with simple or complex programming of the neurostimulator pulse generator/transmitter in the cranial nerve.
  • Codes 95983 and 95984 involve electronic analysis with programming of the neurostimulator pulse generator/transmitter implanted in the brain for the first 15 minutes and for each additional 15 minutes.

Coding Exercise #2

A patient with complications of motor fluctuations due to Parkinson’s disease had bilateral deep-brain stimulation electrode placement three weeks ago. Today he presents for initial programming. A baseline examination is performed along with DBS programming using an initial mapping procedure. Each electrode is tested by gradually increasing the voltage from 0 to 4-6 while observing for any changes and side-effects. Once mapping is complete, the best right and left side electrode and voltage combination is chosen and verified. The total face-to-face time spent on DBS programming is 60 minutes.

CPT: 95983 x 1, 95984 x 3

The DBS is already in place, and analysis and programming are both done here. Programming involves setting the parameters to optimally generate the electrical pulses for stimulation. The total time spent on programming was 60 minutes.

Programming may take place in the operating room, postoperative care unit, inpatient, or outpatient setting. Programming a neurostimulator in the operating room is not inherent in the service represented by the implantation code and may be reported by either the implanting surgeon or other qualified healthcare profession, when performed.

The following table explains the face-to-face time spent with physician or other qualified healthcare professional for the analysis and programming of a deep brain neurostimulator. The appropriate CPT codes are listed based on the time spent.

Parkinson’s and Deep Brain Neurostimulator Coding in CPT
Codes 95983 and 95984 are used to report for electronic analysis with programming of an implanted brain neurostimulator pulse geneartor/transmitter.

Locate and Verify

Just as we did for the above coding exercise, we can find the code for this procedure by looking in the CPT Index under Analysis/implant/neurostimulator pulse generator, 95970-95984. In the Tabular listing, we can verify the correct code as:

95983, electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters) by physician or other qualified health care professional; with brain neurostimulator pulse generator/transmitter programming, first 15 minutes face-to-face time with physician or other qualified health care professional

We are not done however. CPT code 95983 only covers the first 15 minutes of programming. We also need to assign 95984 for the remaining 45 minutes.

95984, Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain neurostimulator pulse generator/transmitter programming, each additional 15 minutes face-to-face time with physician or other qualified health care professional (List separately in addition to code for primary procedure)

Our correct codes are 95983 x 1, 95984 x 3.

CPT codes 95983 and 95984 can be found in the same section of the CPT coding manual as CPT 95970. According to the table provided, 53-67 minutes of brain neurostimulator analysis and programming services are reported as 95983 x 1 + 95984 x 3. Codes 95983 and 95984 are new codes added in 2019 to replace CPT 95978 and 95979 respectively.

These codes are described as:

Per the CPT guidelines:

  • CPT code 95984, an add-on code, should be used in conjunction with 95983.
  • If the face-to-face time is less than eight minutes, it is not reported.

Conclusion

Although there is no cure for Parkinson’s disease, there are treatments available to minimize or prevent the symptoms. Hopefully, you now have a better understanding of the disease and some of the CPT codes related to a generator check and the analysis and programming of a deep-brain stimulator.

** This article has been reviewed and updated as of December 5, 2021. **

Parkinson’s and Deep Brain Neurostimulator Coding in CPT

I submitted this article to BC Advantage/www.billing-coding.com for their publication under the title, “Parkinson’s Disease.” It is reprinted here with their permission.


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