If any disease will cause you to slow down and appreciate life, it’s Parkinson’s disease. Someone I care about was recently diagnosed with an early stage of Parkinson’s and it has been really hard to watch his daily struggles.
I hope this article gives you a better understanding of the disease and helps you with Parkinson’s and deep brain neurostimulator coding.
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.
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.
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.
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 can be more disabling than motor symptoms and may include:
- Cognitive changes: problems with attention, planning, language, memory, or dementia
- Early satiety: feeling full after eating small amounts
- Excessive sweating: when medications are wearing off
- 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
- 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.
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.
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.
- 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.
Treatment is based on the individual’s symptoms and includes such options as medication, surgery, and lifestyle changes.
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 and work in different ways:
- Dopamine Replacement Therapy. Levodopa/carbidopa is the most effective and most commonly prescribed drug for PD. The intestine absorbs levodopa and then the brain converts it into dopamine. Dopamine is the brain chemical that is lacking in Parkinson’s. Carbidopa (Lodosyn) is the medication that prevents levodopa from breaking down in the body so more levodopa can reach the brain and convert to dopamine. Carbidopa also helps lessen or prevent the side-effects of levodopa. If the side-effects cause too much trouble, the dosage of carbidopa can be increased. The combination of levodopa and carbidopa can be taken with other PD medications, or they can be taken by themselves. They also come in different forms, including pills, dissolvable tablet, and a gel (Duopa) that is infused directly into the small intestine. Examples of drugs in this class include Sinemet, Sinemet CR, Stalevo, Parcopa, Rytary, and Duopa.
- Dopamine agonists imitate the effect of dopamine in the brain. These drugs can be taken alone or in combination with other medications such as levodopa/cardiopa. They can be taken in immediate or extended-release forms and by pill, skin patch, or injection. Long-term use of these drugs may be less likely to cause motor complications, such as dyskinesia or “off” time, as compared to levodopa. The motor complications may also be less severe than levodopa, and there are no dietary restrictions with agonists. Examples of drugs in this class include Mirapex, Mirapex ER (pramipexole); Requip, Requip XL (ropinirole); and Neupro (rotigotine), Apokyn (apomorphine).
- Monoamine Oxidase B (MAO-B) Inhibitors reduce the normal activity of an enzyme called monoamine oxidase. This enzyme breaks down dopamine once it has completed its brain activity. MAO-B Inhibitors permit the dopamine that is available to function longer than previously and can be taken alone or with levodopa and other PD therapies based on the specific medication prescribed in this class. Mild symptom relief may be experienced when taken alone in mild Parkinson’s and is an option for those who want to avoid or put off levodopa and dopamine agonists. MAO-B inhibitors can also reduce fatigue and depression in some patients. Examples of drugs in this class include Azilect (rasagiline); Eldepryl, Zelapar (selegiline); and Xadago (safinamide).
- Catechol-O-methyltransferase (COMT) Inhibitors are only used in conjunction with levodopa and prevents levodopa from breaking down outside of the brain. This allows more levodopa to get to the brain and convert to dopamine. These drugs are usually prescribed to increase daily “on” time and decrease “off” time and to help with complications such as when the levodopa wears off early before it is time to take the next dosage. COMT inhibitors may be used instead of prescribing levodopa more often. Examples of drugs in this class include Comtan (entacapone), Stalevo (levodopa/carbidopa and Comtan), and Tasmar (tolcapone).
- Anticholinergic medications reduce acetylcholine, a brain chemical, which restores the already reduced balance caused by PD of this neurotransmitter and dopamine. These medications usually work best to treat tremor and sometimes work for dystonia. In advanced stages of Parkinson’s, these medications can also decrease drooling. Examples of drugs in this class include Artane (trihexyphenidyl) and Cogentin (benztropine).
- Amantadine is often used in early and mild Parkinson’s to reduce motor symptoms. These medications work on the dopamine and glutamate brain chemical pathways and provide different symptom relief based on the medication prescribed in this class. Some PD patients may see reduced fatigue, but they may also experience insomnia. Decreased dyskinesia may also be experienced. Examples of drugs in this class include Symmetrel (immediate-release amantadine), Osmolex ER (amantadine extended-release), and Gocovri (extended-release amantadine).
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.
- Deep Brain Stimulation (DBS). A device 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.
- Insertion of L-Dopa therapy. Surgery is 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.
• Speech-language pathology to improve speech problems
• Healthy diet with focus on those foods that ease symptoms
• Support groups or professionals who deal with chronic illnesses
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.
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.
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).
• 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.
Per 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, 61870, 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.
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:
• 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
• 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)
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.
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