Knowing the correct CPT code for a neurostimulator procedure can be tricky if you don’t know the staged procedures and temporary vs. permanent placement. Follow along and I’ll explain sacral neuromodulation /stimulation coding for this scenario.
Question: A female patient with interstitial cystitis is being seen by her urologist for percutaneous implantation of a neurostimulator electrode array. The neurostimulator electrode array is placed for direct transforaminal sacral nerve stimulation, and fluoroscopic guidance is used to place the electrodes. Assign the correct CPT code.
To find the correct code, look in the CPT coding manual Index under Sacral Nerve/ neurostimulator electrode implants, incisional/percutaneous 64561. CPT code 64561 can be verified in the Tabular as:
- 64561 – Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed
AMA guidelines state:
“(For percutaneous electrical neuromuscular stimulation or neuromodulation using needle[s] or needle electrode[s] [eg, PENS, PNT], use 64999).”
This CPT code is located in the Surgery section under Surgical Procedures on the Nervous System/Surgical Procedures on the Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System.
The Neurostimulator Procedures on the Peripheral Nerves include CPT codes 64553, 64555, and 64561 to report both temporary and permanent placement of percutaneous electrode arrays. The codes are based on the nerve that is targeted.
Sacral neuromodulation, or sacral nerve stimulation, is considered the fourth line of treatment for interstitial cystitis symptoms such as pain, urinary frequency, and urinary urgency. Once a patient has undergone other more conservative treatments without success, an initial trial testing phase of sacral neuromodulation (SNM)/sacral nerve stimulation (SNS) may be warranted. SNM/SNS is usually done as a staged procedure, and programming, monitoring and revision surgery is often needed.
Basic Test/Percutaneous Nerve Evaluation
This initial trial testing phase is referred to as the Basic Test, or percutaneous nerve evaluation (PNE). It is also known as a peripheral nerve evaluation. The purpose of this trial procedure is to determine the effectiveness of sacral neuromodulation (SNM) and to determine if an implantable stimulator should be placed permanently.
According to the American Urogynecologic Society (AUGS), this temporary external stimulation test is done in the physician’s office under local anesthesia. Temporary test electrodes are placed into the sacral foramen for direct transforaminal stimulation of the sacral nerve. A spinal needle is used to locate the sacral nerve(s), and a neurostimulator electrode array is placed for direct transforaminal stimulation of the sacral nerve. There it remains for a period of several days. The procedure is usually done on both sides and with fluoroscopic guidance (if it is available in the office). The patient will keep a voiding diary over the next several days and return for follow-up and discussion of test stimulation results.
Coding for Bilateral Sides
Since the procedure is typically done on both sides, and they are each done separately, CPT 64561 should be reported twice, and modifier 50 (bilateral procedure) should be appended to one of the codes. As the American Urogynecologic Society (AUGS) states, there is no need to report a separate CPT code for the fluoroscopic imaging since it is already included in CPT 64561. Removal of the electrodes is not coded separately since it is usually done during the 10-day global period.
Documentation should provide the patient’s symptoms of urinary urgency, urinary frequency, or urinary retention, along with any known etiologies such as interstitial cystitis. The documentation should also indicate previous therapeutic measures that have failed.
According to United Healthcare, sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention when the following criteria are met:
- Patient must have had other therapies that proved unsuccessful, such as behavioral, pharmacologic, and/or surgical corrective therapy, and it must be documented. The patient must also be an appropriate candidate for implantation with anesthesia.
- Patient must have had a test stimulation that resulted in 50% or greater improvement by proof of voiding diaries.
- Patient must be able to show the ability to record voiding diary data so that the results of the implant procedure can be appropriately evaluated.
The test stimulation and the permanent implant are both covered procedures under these guidelines.
Exclusions to this coverage include patients with stress incontinence, urinary obstruction, and neurologic diseases such as diabetes and peripheral nerve involvement. This is due to the fact that these conditions are associated with secondary manifestations of urinary urge incontinence, urgency-frequency syndrome, and urinary retention
Be sure to check with the individual carriers, including Medicare, to ensure coverage and check for any coverage exclusions.
Sacral nerve neuromodulation/stimulation is a procedure performed only after other conservative measures have been tried unsuccessfully. For patients with interstitial cystitis, it is the fourth line of treatment done as a temporary means to determine if permanent placement of a neurostimulator is in order. Coders should pay close attention to the provider’s documentation and apply the coding guidelines and conventions for each staged procedure.