Did you know that the Office of Inspector General (OIG) released an audit report in 2021 for neurostimulator implant surgeries billed to Medicare in 2016 and 2017? This report revealed that the federal program overpaid $636 million in claims during that timeframe. Additionally, 48 out of 106 audited claims lacked documentation supporting the medical necessity.
These findings resulted in stricter reimbursement guidelines for procedural codes, such as CPT code 63685. Thus, we decided to break down the essential billing requirements and applicable modifiers for this service. So, if you are a pain management specialist who deals with neurostimulator implant surgeries, continue reading!
CPT Code 63685 – Description
CPT code 63685 covers the insertion or replacement of a spinal neurostimulator pulse generator or receiver. It involves creating the storage pocket and linking the battery to the electrodes placed in the spine.
Scenarios Where CPT Code 63685 is Applicable
Let’s review a few real-world clinical scenarios related to CPT 63685:
Initial Permanent Insertion Following a Successful Trial
Picture a 57-year-old male patient with a confirmed diagnosis of failed back surgery syndrome (FBSS). The condition causes intractable pain in his left leg. The patient has successfully completed a one-week trial stimulation that provided 80% pain relief.
Therefore, the surgeon implants the permanent neurostimulator system in two parts.
First, he permanently secures the previously placed temporary percutaneous leads. In the second phase, he creates a subcutaneous pocket in the right flank and tunnels the lead extensions to the pocket. The rechargeable implantable pulse generator (IPG) is connected to the lead and secured within the pocket.
Here, the surgeon should report CPT code 63685 to bill for the insertion of the IPG.
Routine Battery Depletion and Replacement
Assume a 70-year-old female patient with complex regional pain syndrome (CRPS). She was implanted with a non-rechargeable (primary cell) spinal neurostimulator 8 years ago to manage the pain. Over the years, the system worked perfectly fine. However, the battery reached its end of life.
As a result, the patient is scheduled for a prophylactic replacement before the battery fully depletes. During the procedure, the surgeon accesses the existing subcutaneous pocket in the patient’s abdomen. He removes the old IPG by disconnecting it from the leads. The provider then connects a new, non-rechargeable neurostimulator to the existing, functional leads. Finally, he secures the pocket.
You should report CPT code 63685 to bill for the replacement of the pulse generator.
Generator Replacement Due to Hardware Malfunction
Imagine a 47-year-old male patient with a newly implanted IPG. He comes back to the clinic 18 months after the implantation, and complains about intermittent system failure.
The healthcare practitioner examines the device and confirms that the IPG is faulty while the leads are fine. As a result, he makes an incision over the existing generator pocket. He removes the faulty IPG and implants a new, functional pulse generator.
Here, CPT code 63685 applies.
Applicable Modifiers for CPT Code 63685
Discussed below are the applicable modifiers for CPT 63685:
Modifier 51
What happens when the physician performs the insertion of the IPG (CPT code 63685) and insertion of the spinal leads (CPT 63650) during the same surgical session?
You append modifier 51 to inform the payer to reimburse the primary procedure at 100% and release 50% payment for the secondary procedure.
Modifier 62
Modifier 62 indicates that two surgeons worked together as co-surgeons during the same surgical procedure. Each of these surgeons acts as a primary surgeon and performs a distinct, non-overlapping part of the service.
Modifiers 80, 81, 82 & AS
When the primary surgeon takes help from an assistant surgeon during the pulse generator insertion or replacement, the assistant at surgery must report CPT code 63685 with a relevant modifier:
- Modifier 80: It indicates that an assistant surgeon assisted the primary surgeon.
- Modifier 81: It represents that minimal surgical assistance was rendered by the assistant surgeon.
- Modifier 82: It is used specifically in teaching facilities when a non-resident assistant surgeon assists the primary surgeon.
- Modifier AS: It is used when a nurse practitioner (NP), physician assistant (PA), registered nurse first assistant (RFNA), or clinical nurse specialist (CNS) renders surgical assistance.
CPT Code 63685 – Billing & Reimbursement Guidelines
The following are the essential billing guidelines related to CPT 63685:
Establish Medical Necessity
The payer will not reimburse if you straightaway advise the patient on a permanent implantation of a neurostimulator for pain management. You must justify that the non-surgical techniques for chronic pain management failed.
Discussed below are the key requirements to justify the medical necessity of performing the procedure covered under CPT code 63685:
- Explain that the patient experienced severe chronic pain that persisted for more than six months.
- Medical records must verify that conservative treatment failed to manage the pain, including medications, physical therapy, injections, etc.
- Before implanting a permanent neurostimulator pulse generator, the physician must first perform a successful trial phase. For context, a successful trial is one that relieves the patient’s pain by at least 50% or more.
- Confirm psychological clearance of the patient. That is, there are no untreated conditions that could compromise the success of the implant, e.g., drug dependency, depression, etc.
- Link the CPT code 63685 to the most appropriate ICD-10-CM code, e.g., G89.4 (chronic pain syndrome), M54.4 (lumbago with sciatica), etc.
- In case you are billing for the implant replacement, explain the reason, e.g., the battery life depletion, confirmed hardware malfunction, etc.
Fulfill Documentation Requirements
Comprehensive documentation is not just a billing best practice, but a key to preventing denials. Thus, if you want CPT code 63685 to get reimbursed on time, include the following:
- Prove the trial success by referring to the trial stimulation report. It must include the trial date along with the documented percentage of pain relief achieved.
- Attach the relevant imaging reports (MRI, CT scan, etc.) to confirm the lead placement site.
- Mention the unique device identifier (UDI) serial number and the manufacturer’s name for the pulse generator or receiver.
- State the anatomical location where the surgeon created the subcutaneous pocket.
- Describe the tunneling of the extension cable and the method used to connect and secure the implant to the lead extensions.
- Verify the interrogation of the system and confirm that it was functioning accurately before the incision was sealed.
- Document the removal of the old device (in case of replacement).
Append Appropriate Modifier (When Needed)
You should also use modifiers when required to ensure coding specificity. Some of the applicable modifiers for insertion or replacement of a pulse generator or receiver are 51, 62, 80, 81, 82, and AS.
Refer to the ‘Applicable Modifiers for CPT Code 63685’ section to understand their appropriate usage guidelines.
Also, the documentation must support the use of modifiers. For instance, if you are appending modifier 62, supporting documentation should justify the need for co-surgeons.
Summary
Are you a pain management specialist struggling to bill for the insertion or replacement of a device covered under the CPT code 63685? If yes, just remember a few key details while reporting this procedural code.
You must confirm that a successful trial stimulation was performed, which resulted in at least a 50% reduction in pain. Besides, you should acquire pre-authorization from the payer and append relevant modifiers based on the circumstances.
Following these best practices will help you reduce the likelihood of claim denials, leading to a steady cash flow.
However, if you still find it challenging to handle on your own, feel free to outsource pain management billing services to MediBillMD.
