A widely used treatment modality for managing different chronic pain stages, spinal cord stimulation delivers low-level electrical signals to the spinal cord or to specific nerves to block pain signals from reaching the brain. Typically, implanted or placed under the skin, the spinal cord stimulator (a small device similar to a pacemaker) delivers electrical pulses to the spinal cord area to mask or modify the level of pain. Typically, the stimulation procedure does not eliminate the source of pain, but it simply interferes or changes the way the brain perceives it. As a result, the amount of pain relief varies from one person to another. The basic goal of the procedure is a 50-70 percent reduction in pain. However, even a small reduction in the level of pain can be quite significant if it helps a person to perform his/her day-to-day activities with less pain and reduces the amount of pain medication consumed. But spinal cord stimulation does not work for everyone. The procedure may be a perfect option for people who suffer from chronic back, leg or arm pain and do not get any significant relief with other therapies. It is generally recommended when other treatments have not been successful, when surgery is not likely to help, or when surgery has failed. Pain management medical billing and coding can be complex and tricky for diverse clinical specialties. For timely reimbursement of complex pain management procedures, ambulatory surgery centers (ASCs) should ensure proper claims submission with accurate medical codes. Medical billing outsourcing is a perfect option for ASCs to smoothen their billing process and submit claims within the specified time limit.
What Is Spinal Cord Stimulation Used For?
Spinal cord stimulation is generally used when other non-surgical treatment options fail to provide sufficient pain relief. Typically, spinal cord stimulators (SCS) are used to treat or manage different types of chronic pain, including –
- Back pain (especially back pain that continues even after surgery)
- Post-surgical pain
- Nerve-related pain (such as severe diabetic neuropathy and cancer-related neuropathy from radiation, surgery or chemotherapy)
- Injuries to the spinal cord
- Arachnoiditis (painful inflammation of the arachnoid – a thin membrane that covers the brain and spinal cord)
- Visceral abdominal pain and perineal pain
- Peripheral vascular disease
- Pain after an amputation
- Complex regional pain syndrome
The procedure can help improve the overall quality of life and sleep, and reduce the need for pain medications. The procedure is normally administered along with other pain management treatments like exercise, physical therapy, medications and other relaxation methods.
Who Is an Ideal Candidate for Spinal Cord Stimulation?
As with all other treatment options, the physician will at first evaluate or make sure whether spinal cord stimulation is the right treatment choice for managing chronic pain. For this, the physician will evaluate the patient’s physical condition, medication regime and pain history to correctly determine whether the goals of pain management are appropriate for SCS. Pain management specialists or neurosurgeons will perform a detailed review of all previous treatments and other surgical procedures performed. As chronic pain also involves emotional effects, a psychologist will conduct a screening to assess the patient’s condition to maximize the probability of a successful outcome. In addition, imaging tests may also be recommended as an option.
As each patient is different, people who benefit from the most from spinal cord stimulation must have experienced chronic debilitating pain for more than 3 months in the lower back, leg (sciatica), or arm. They also typically have had one or more spinal surgeries. A patient may be an ideal candidate for SCS if –
- Conservative therapies have failed
- Patients do not benefit from additional surgical procedures
- Patients should not have untreated depression or drug addiction (as these should be treated prior to having a SCS)
- Patients should not have any medical conditions that would prevent them from undergoing implantation
- Patients have had a successful SCS trial
- Pain is caused by a correctable problem and should be fixed
Spinal Cord Stimulation – What the Procedure Involves
Neurosurgeons and doctors who specialize in pain management (an anesthesiologist or physiatrist) implant spinal cord stimulators. Spinal cord stimulators involve two specific procedures – to test and implant the device, and the trial and the implantation.
- Spinal Cord Stimulator Trial – The first step is a trial period. The surgeon will implant a temporary device. The surgeon will carefully insert the electrodes in the epidural space of the spine. The type and location of pain affects where these electrodes will be placed along the spine. Surgeons may ask for patient feedback during the procedure to best position the electrodes. The trial procedure typically requires only one incision in the lower back area to place the electrodes. The surgeons will generally evaluate how well the device worked for about a week. If the patient experiences about 50 percent or greater reduction in pain level, the trial is considered a success and a surgery will be scheduled to permanently implant the device. On the other hand, if unsuccessful, the wires can easily be removed in the clinic without damage to the spinal cord or nerves.
- Spinal Cord Stimulator Implantation – Typically performed as an outpatient procedure, the implantation procedure can take about 1-2 hours. The procedure begins by administering local anesthesia and making incisions. One incision will be made along the lower abdomen or buttocks to hold the generator and another incision will be made (along the spine) to insert the permanent electrodes. As in the trial procedure, fluoroscopy is used to determine where the electrodes are to be placed. Once the electrodes and generator are connected and running, the surgeon will close the incisions.
In most cases, patients leave the surgery center the same day after the procedure – once the anesthesia effect gets reduced completely. There will be mild pain for several days after the surgery. Patients may be advised not to stretch, twist or reach, which could pull the incisions. Dressings placed over the incision sites can be removed after 3 days. In most cases, incisions heal within about 2-4 weeks after surgery. Physicians as part of the recovery plan will recommend lighter activity for about 2 weeks after surgery. As mild complications and risks are typically involved in every procedure, patients undergoing spinal cord stimulator surgery may experience – infection (occurring within the first 2-8 weeks), bleeding, device migration (electrodes move from their original location and the stimulator doesn’t block pain as effectively), device damage and spinal cord trauma.
Reporting Spinal Cord Stimulation
Medical billing and coding for spinal cord stimulation can be challenging, as it involves numerous rules related to reporting the procedure accurately. Neurosurgeons or other physicians administering spinal cord stimulation must use the relevant CPT codes to bill for the procedure correctly.
The CPT codes for spinal cord stimulation include –
- 63650 – Percutaneous implantation of neurostimulator electrode array, epidural [not covered for dorsal root ganglion stimulation] [not covered for dorsal column stimulation]
- 63655 – Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
- 63661 – Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
- 63662 – Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
- 63663 – Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
- 63664 – Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) 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
- 64561 – Sacral nerve (transforaminal placement), including image guidance, if performed
- 64590 – Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling
Analysis and Programming
CPT codes 95970–95973 are used to report electronic analysis services. These are not considered medically necessary when provided at a frequency more often than once every 30 days. More frequent analysis may be necessary in the first month after implantation.
- 95970 – Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and 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, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming
- 95971 – Simple spinal cord, or peripheral (i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming
- 95972 – Complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming
- A4290 – Sacral nerve stimulation test lead, each
- C1767 – Generator, neurostimulator (implantable), non-rechargeable
- C1778 – Lead, neurostimulator (implantable)
- C1787 – Patient programmer, neurostimulator
- C1816 – Receiver and/or transmitter, neurostimulator (implantable)
- C1820 – Generator, neurostimulator (implantable), non-high-frequency with rechargeable battery and charging system
- C1822 – Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system
- C1883 – Adaptor/extension, pacing lead or neurostimulator lead (implantable)
- E0745 – Neuromuscular stimulator, electronic shock unit
- L8679 – Implantable neurostimulator, pulse generator, any type
- L8680 – Implantable neurostimulator electrode, each [not covered for dorsal column stimulation]
- L8681 – Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
- L8682 – Implantable neurostimulator radiofrequency receiver
- L8683 – Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
- L8684 – Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement
- L8685 – Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
- L8686 – Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
- L8687 – Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
- L8688 – Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
- L8689 -External recharging system for battery (internal) for use with implantable neurostimulator, replacement only
- L8695 – External recharging system for battery (external) for use with implantable neurostimulator, replacement only
Generally, the pain relief provided by spinal cord stimulators allows patients to do much more than they could before surgery. However, there are but there are certain restrictions that patients need to be careful.
Pain management medical billing and coding require adequate knowledge regarding appropriate codes and modifiers. Payer-specific medical billing is essential for correct and on-time reimbursement. With all the complexities involved, the support of a reliable and established medical billing service provider can be helpful for reporting the SCS procedure correctly.