Implantation of Spinal Neurostimulator

The Centers for Medicare & Medicaid Services (CMS) covers the implantation of central nervous system stimulators as a therapy for the relief of chronic intractable pain. 

A dorsal column (or spinal cord) neurostimulator is the surgical implantation of neurostimulator electrodes within the dura mater (endodural) or percutaneous insertion of electrodes in the epidural space.

The spinal cord neurostimulator system consists of four components: the generator (or “pulse generator”), the electrical leads, a remote control and a battery recharger.

Part I: The Generator 
A temporary spinal neurostimulator does not include the implantation of a generator. A permanent spinal neurostimulator does include the implantation of a generator into the abdomen, flank or buttocks. Some descriptions also call this an implantable pulse generator (IPG). 

Part II: The Electrical Leads (and Extensions)
These are the “wires” connected to the generator. The extension is the insulated wires tunneled under the skin and the “leads” are the exposed electrodes placed in the epidural space. This is usually completed percutaneously but can be via the surgical approach where the spine is surgically opened to the epidural space, usually performed with a hemilaminectomy.

Part III: The Remote Control

Part IV: Battery Charger

Coverage
Providers who plan to perform both the trial and permanent implantation procedures using CPT^® code 63650 in the hospital outpatient department (OPD) will only be required to submit a prior authorization request (PAR) for the trial procedure. To avoid a claim denial, providers must place the Unique Tracking Number (UTN) received for the trial procedure on the claim submitted for the trial and permanent implantation procedure. When the trial is rendered in a setting other than hospital OPD, providers will need to submit a PAR for CPT 63650, as part of the permanent implantation procedure in the hospital OPD.

Documentation Requirements 

• Indicate if request is for a trial or permanent placement 
• Physician office notes including: 
  • Condition requiring procedure 
  • Physical evaluation 
  • Treatments tried and failed including but are not limited to: 
    • Spine surgery 
    • Physical therapy 
    • Medications
    • Injections 
    • Psychological therapy 
• Documentation of appropriate psychological evaluation 
• For permanent placement, include all of the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s)
  • A successful trial should be associated with at least a 50 percent reduction of target pain or 50% reduction of analgesic medications

Best Practices, Documentation Feedback and Tips

Trial
The purpose of the implantation trial is to determine if a spinal cord stimulator will be effective in relieving the pain. The generator remains external during a trial implantation. Use CPT code 63650 for the temporary percutaneous epidural implantation of the neurostimulator electrode array.

Permanent
For permanent implantation, the electrical leads are advanced in the epidural space to a specific level desired. Most Spinal Neurostimulator systems are performed with a bilateral lead to allow for placement on the left and right side of the spinal column. Use CPT code 63650 for the permanent percutaneous epidural implantation of the neurostimulator electrode array. This is the same code as used for the temporary lead placement.

If placing a second lead, the provider will bill 63650 for the first lead. The second lead is billed using the 59 modifier. Use 63650-59 for each additional percutaneous lead placed. The modifier 50 is not used. The modifiers RT and LT are not used. 

If the temporary lead(s) are NOT removed when the permanent implantation is performed (i.e., the temporary leads are converted to a permanent lead), there is NO coding for the 63650. 

Replacement
When the battery in the generator has worn out, the entire generator must be replaced. The diagnosis for this procedure is a V code (V53.02). The replacement of the generator does not require the removal or replacement of the electrical leads. 

If a different spinal level is selected for the lead replacement, the physician should bill CPT 63650 for implantation of the new percutaneous lead. 

Related Content: National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7).