Spinal cord stimulation (SCS) is widely used to treat various chronic pain states. Implanted in the body, the spinal cord stimulator delivers electrical pulses to the spinal cord which modify and prevent the pain signal from reaching the brain.
SCS is covered by most health insurance plans, including Medicare, private payers, and most workers’ compensation programs. Services provided for any given diagnosis must meet all of the general requirements for medical necessity as stated in CMS payment policy manuals, CMS national coverage determinations, and Medicare payment rules. Pain management medical coding services are available to help physicians report the CPT codes that reflect SCS services provided to each patient in the office or hospital/ASC setting.
- Spinal Cord Stimulation – Procedure and Patient Selection Criteria
The neurostimulator electrodes used for SCS are implanted percutaneously in the epidural space using a special needle. In some cases, an open procedure requiring laminectomy to place the electrodes may be needed. The trial may be conducted using temporary electrodes. After placing the electrodes, the patient is initially provided with an external neurostimulator on a trial basis. The trial period can last up to four weeks. The electrodes may be removed it is determined during the trial period that the modality is not effective, or it is not acceptable to the patient. If the trial succeeds, a spinal neurostimulator and pulse generator are inserted subcutaneously and connected to the implanted electrodes. SCS is an appropriate treatment for chronic neuropathic pain patients meeting the following criteria:- Other treatment modalities are unsuccessful or are unsuitable or contraindicated.
– The patient has undergone careful screening, evaluation, and diagnosis by a multidisciplinary team.
– All facilities, equipment and personnel required for the proper diagnosis, treatment, training and follow-up of the patient are available.
– The patient experiences adequate pain relief in a clinically appropriate screening trial. The permanent implantation is done only after this.
CPT/HCPCS Codes for SCS
CPT Codes
- Percutaneous Leads and Extensions
63650 Percutaneous implantation of neurostimulator electrode array, epidural
63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed - Paddle Leads
63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, 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 - Stimulators
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 - 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 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 brain, spinal cord, or peripheral (i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming
95972 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); complex brain, spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour
95973 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); complex brain, spinal cord, or peripheral (except cranial nerve); complex brain, spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, additional 30 minutes after hour
HCPCS Codes
C1767 Generator, neurostimulator (implantable), non-rechargeable
C1778 Lead, neurostimulator (implantable)
C1816 Receiver and/or transmitter, neurostimulator (implantable)
C1820 Generator, neurostimulator (implantable), 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)
C1897 Lead, neurostimulator test kit (implantable)
L8679 Implantable neurostimulator, pulse generator, any type
L8680 Implantable neurostimulator electrode, each
L8682 Implantable neurostimulator radiofrequency receiver
L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
L8686 Implantable neurostimulator pulse generator, single array, 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
L8699 Prosthetic implant, not otherwise specified. L8699 should be used to bill for trial stimulator
Outpatient hospitals should use C codes when reporting devices to Medicare. For instance, in a hospital outpatient setting, a neurostimulator lead is reported using C1778 Lead, neurostimulator (implantable). This HCPCS Level II code is reported and reimbursed per lead (array) rather than per electrode (contact point).
General Coding Guidelines
- Do not report 63661 when removing or replacing a temporary percutaneously placed array for an external generator.
- Do not report 63663 when removing or replacing a temporary percutaneously placed array for an external generator. Do not report 63663 in conjunction with 63661, 63662 for the same spinal level.
- Do not report 63664 in conjunction with 63661, 63662 for the same spinal level.
- Do not report 63685 in conjunction with 63688 for the same pulse generator or receiver.
- Code 95973 should be listed separately in addition to code for primary procedure and used in conjunction with code 95972.
- Medicare does not allow separate payment for implanted neurostimulator devices in an ASC. The surgical procedure codes are considered to be device-intensive procedures and, as such, reimbursement for the implants is included in the payment for the surgical procedure.
Here are some clarifications on CPT coding for SCS leads from medical device company Medtronic:
- Lead implantation codes 63650 and 63655 are defined and assigned according to the approach, not according to the type of lead. Code 63650 is usually assigned for implantation of a “catheter-like” lead and code 63655 is typically assigned for a “plate or paddle-shaped” lead. Code 63650 is defined as percutaneous implantation, regardless of how the lead is shaped. Code 63655 is defined as implantation via laminectomy and cannot be reported if laminectomy did not take place.
- Code 63650, percutaneous epidural implantation of neurostimulator electrode array, is assigned for inserting both temporary and permanent percutaneous leads.
- For temporary percutaneous trial leads, removal is inherent to the original insertion and is not reported using a separate code.
- Codes 63661 and 63662 for removal of lead(s) apply only to surgical removal of permanent leads, that is, removal of a permanent lead by simple pull is not coded.
- Codes 63663 and 63664 are defined as “revision including replacement” of lead(s). For replacements, these codes are used only when a permanent lead is being replaced with another permanent lead, and the original lead and the new lead are the same type placed via the same approach.
- Tunneling of leads is not coded separately and is included in the code for implanting the generator.
Medtronic also clarifies that there are specific rules for reporting different scenarios. For instance, when a temporary (trial) percutaneous lead is removed and replaced by a permanent paddle lead via a fresh laminectomy at the same spinal level, 63655 should be reported.
Providers should consult with their payer on reporting options for implantable devices and relevant accessories. Medicare has an established National Coverage Determination (NCD) for spinal cord stimulators. In addition to the NCD criteria, some Medicare contractors may require additional SCS coverage criteria through local coverage determinations (LCD). For the Medicare outpatient hospital setting, C-Codes are required for billing with applicable CPT codes, but they are not separately payable by Medicare. For most non-Medicare plans, L-Codes or Revenue Codes may be appropriate for reporting purposes. Payer organizations also periodically update medical policy and criteria. Claims submitted for spinal cord stimulation must also include appropriate ICD-10 codes. Providers should maintain documentation supporting medical necessity in the patient’s medical record and make it available to the payer upon request.
Multiple codes and differences in third-party payer guidelines can make reporting spinal cord stimulator-related procedures quite complex. Partnering with an experienced medical billing and coding company would a practical option for neurosurgeons and pain management physicians to report the procedures correctly and ensure proper reimbursement.
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