SCS Programming CPT code question

[Timeoutofmind]

I have gotten a half a dozen different answers from people who I have asked about this.

Do you bill for simple (95971) or complex (95972) programming after SCS trial placement? Perm placement?

Below are the criteria. I guess my thought process is that technically speaking...the rep definitely programs at least three of those variables for both the trial and the perm, so 95972 would be appropriate for both the trial and the perm.

Having said that, we are not directly involved in the programming at all. The rep does it all. There does not seem to be any guidance as far as if it is required that the physician actually be involved in or guiding the programming process.

Would appreciate your thoughts.

Seems like people are all over the place with what charges they submit. Anyone ever been audited or gotten negative feedback from billers on this?

Any documentation you submit to support the billing?



CPT Neurostimulator Programming:



Intraoperative or subsequent programming of the neurostimulator pulse generator/transmitter includes changes to the following parameters:

· Rate,

· Pulse amplitude,

· Pulse duration,

· Pulse frequency,

· Eight or more electrode contacts,

· Cycling,

· Stimulation train durations,

· Train spacing,

· Number of programs,

· Number of channels,

· Alternating electrode polarities,

· Dose time (stimulation parameters changing in time periods of minutes including dose lockout times),

· More than one clinical feature (eg, rigidity, dyskinesia, tremor)


· Simple intraoperative or subsequent programming of the neurostimulator pulse generator/transmitter includes changes to three or fewer of these parameters.


· Complex intraoperative or subsequent programming of the neurostimulator pulse generator/transmitter includes changes to more than three of these parameters.



CPT Code

Description

95970

Electronic analysis of implanted Neurostimulator pulse generator system (e.g., rate, pulse amplitude, pulse 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 (i.e., cranial nerve, peripheral nerve, sacral nerve, neuromuscular) Neurostimulator pulse generator/transmitter, without reprogramming.



95971

Electronic analysis of implanted Neurostimulator pulse generator system;

simple spinal cord or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) Neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming.



95972

Electronic analysis of implanted Neurostimulator pulse generator system;

complex spinal cord or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) Neurostimulator pulse generator/transmitter, with intra-operative or subsequent programming.



Resource:



Current Procedural Terminology (CPT), Professional Edition, 2018, AMA

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[Orin]

Most of the manufacturers recommend that if the physician or staff do not do it or direct it, the billing should not be performed. I prefer not to charge the patient for a visit, co-pay, facility fee, etc, but you do you.

For example:

https://s21.q4cdn.com/478267292/fil...-Physician-Reimbursement-and-Coding-Guide.pdf
Note: Analysis and programming of spinal cord stimulator systems may be provided by the treating physician, practitioner, or axillary medical personnel (in accordance with the Medicare or relevant payer “incident-to” requirements) under the direct supervision of physician (or other practitioner), with or without support from a manufacturer’s representative. A physician should not bill if the service is performed under the direction of, or entirely by, a manufacturer representative without payer consent. Nevro recommends that the insurance carrier be contacted for interpretation of applicable coding and billing policies.

The guides from other companies are similar.

Obviously if you do it yourself or tell the rep where/what/how to do it, then do bill. Intra-op/peri-op I generally try to do enough to feel involved, and that's an easy CPT to add, but for pre-/post- MRI checks or adjustments, I don't.

 

[lonelobo]

Seen a lot of Fraud where doctors are billing with rep doing everything

 

[painfree23]

Seen a lot of Fraud where doctors are billing with rep doing everything

So if we help the rep, what code can we use?

 

[Agast]

Interestingly it looks like the fee schedule ranges from $42-65 for programming. I could see why it would be attractive to docs who pad their bills.