95974 – Electronic analysis of implanted neurostimulator pulse generator system (eg,rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour
General practice is for the neurosurgeon alone to bill for the surgery. He/she makes the pocket as well as placing and evaluating the leads. A separate procedure code for electronic analysis services may be appropriate if the neurologist/neurophysiology team adjusts and initiates initial stimulus levels in the operating room. Co-surgeons are not necessary. Standby services are not covered. Assistant-at-surgery is not payable for these procedures.
An evaluation and management (E&M) visit may be separately paid with the same date of service as a neurostimulator analysis (95970-95975) only if the visit constituted a significant and separately identifiable service. The physician needs to satisfy the elements of an E&M visit (e.g., history, exam, medical decision making), and the patient record must reflect the medical necessity of a separately identifiable E&M (e.g., patient has new or changed symptoms, analysis of neurostimulator reveals need for additional exam, etc.). If the physician merely analyses an implanted neurostimulator pulse generator system, no E&M may be paid. To indicate it is a separately identifiable service, use the -25 modifier.
When VNS is performed for indications other than intractable epilepsy the service should be billed with either a GA or a GZ modifier and the claim will be denied as not medically necessary.
Vagus Nerve Stimulation is covered
Vagus Nerve Stimulation may be considered medically necessary when both of the following criteria are met:
1. The patient has medically refractory seizures, and
2. The patient has failed or is not eligible for surgical treatment.
Vagus Nerve Stimulation is not covered
Vagus nerve stimulation is considered investigational as treatment for the following conditions, including but not limited to:
1. indications that do not meet the criteria listed above
2. patients who can be treated successfully with anti-epileptic drugs
4. essential tremor
7. heart failure
10. traumatic brain injury.
Non-implantable vagus nerve stimulation devices are considered investigational for all indications.
Referral Required – No
Authorization required – Yes
Vagus nerve stimulation (VNS) is proven and medically necessary for treating epilepsy in patients with all of the following:
** Medically refractory epileptic seizures
** The patient is not a surgical candidate or has failed a surgical intervention
** No history of left or bilateral cervical vagotomy
The U.S. Food and Drug Administration (FDA) identifies a history of left or bilateral cervical vagotomy as a contraindication to vagus nerve stimulation.
It is an expectation that the physician have experience and expertise in the use of vagus nerve stimulation.
Billing/Coding/Physician Documentation Information
This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.
Applicable service codes: 61885, 61886, 61888, 64553, 64568, 64569, 64570, 64585, 95970, 95974, 95975,L8679, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689
Vagus Nerve Stimulation Covered ICD codes
Diagnoses that are subject to medical necessity review: 278 – 278.03, 296, 296.2, 296.2x, 296.3, 296.3x, 296.5, 296.5x. 296.8, 296.82, 307.81, 311, 333.1, 346 – 346.9x, 428-428.9, 625.4, 627.2, 729.1, 784.0
ICD-10 Diagnosis Codes:E66.01, E66.2, E66.3, E66.9, F31.30, F31.31, F31.32, F31.4, F31.5, F31.75, F31.76, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.8, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.9, G24.211, G24.219, G24.221, G25.0, G25.1, G25.2, G43.B0, G43.001, G43.009, G43.011, G43.011, G43.019, G43.101, G43.109, G43.111, G43.119, G43.401, G43.409, G43.411, G43.419, G43.501, G43.509, G43.511, G43.519, G43.601, G43.609, G43.611, G43.619, G43.701, G43.709, G43.711, G43.719, G43.801, G43.809, G43.811, G43.819, G43.821, G43.829, G43.831, G43.839, G43.901, G43.909, G43.911, G43.919, G43.A0, G43.A1, G43.B1, G43.C0, G43.C1, G43.D0, G43.D1,G44.1, G44.201, G44.209, G44.229, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9, M60.80, M60.811, M60.812, M60.819, M60.821, M60.822, M60.829, M60.831, M60.832, M60.839, M60.841, M60.842, M60.849, M60.851, M60.852, M60.859, M60.861, M60.862, M60.869, M60.871, M60.872, M60.879, M60.9, M79.1, M79.7, N94.3, N95.1, R51
Do we need to document "time" when using this CPT code (95974)?
In the case of 95974, it notes one hour, without or with programming. I am not sure you need to document the time, except make sure that it is in the encounter notes. Guidelines also note that the # of adjustments made may also influence which code is used (95971 = three or less adjustments); 95972-95979) is four or more. Most of the time the "time" is not noted but the # of adjustments to the programming are noted. That may be more important to code.