AANS Neurosurgeon | Volume 28, Number 4, 2019


Coding Pain Should Not Be a Pain

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For decades, pain surgery has been neurosurgery’s stepchild. Few took interest in it, lesioning of the nervous system suffered the stigma inflicted by psychosurgery, and the field was being slowly absorbed by anesthesiology and physiatry. Luckily, the neurosurgeon’s attitude towards humanity’s most prevalent chief complaint is changing. Along with changing attitudes come changing techniques and technologies, which are making surgical pain management far more palatable. Throw in clinical quality measures, meaningful use and the national war on prescription opioids, and we have the perfect storm brewing, perhaps a tsunami, that will sweep certain attitudes towards pain management into the abyss, allowing the field to reclaim its role in the neurosurgical spotlight.

Today’s world of neurosurgical pain management would be unrecognizable to William Sweet and his contemporaries. Neuromodulation is the name of the game and is one of the fastest growing fields in all of medicine. The vocabulary of the field has also changed dramatically, with the introduction of terms such as high-frequency spinal cord stimulation (SCS), burst stimulation, dorsal root ganglion stimulation and occipital nerve stimulation. These are procedures are relatively quick, minimally invasive, do not require a hospital stay and are optimized for functional restoration, return to work and diminution of opioid use. In spite of the rapid pace of the field, the coding aspects are moving at a snail’s pace. As it relates to CPT coding, the coding simply has not caught up with clinical practice. This has the benefit of allowing for great simplicity in the current way of coding but is not representative of reality and leaves a number of diagnoses and procedures without reimbursable coding at all.

The workhorse of neurosurgical pain management is SCS:

  • Percutaneous implantation of an array: 63650
  • Paddle placement via laminectomy: 63655
  • Pulse generator implantation: 63685

But, how about percutaneous placement of a paddle? This falls under 63650, but the skill set and underlying principles are different than your standard cylindrical array. This coding needs to be re-examined. Similarly, dorsal root ganglion lead implantation codes as 63650. This too involves a vastly different skill set, a different set of principles and specialized training. Where the coding truly rears its obsolete head is with programming of these devices: 95972. Programming of traditional spinal cord stimulators versus non-traditional systems are very different skill sets. A waveform is not just a waveform anymore, and the programming considerations are ever more specialized. For example, when programming a patient with burst stimulation, we are looking for pain relief, but we are likely to be treating the patient’s anxiety and depression as well. How is this accounted for in the coding? We won’t even open up the Pandora’s box of dorsal root ganglion stimulation, but suffice it to say, programming codes lag behind technological advances in neuromodulation.

ICD pain diagnosis coding also lags behind the clinical reality. We effectively treat lumbago with SCS these days, and the data to support this therapy is strong. Your patient will be thankful and will reclaim his/her quality of life. Unfortunately, M54.5 will not get you paid for 63650 (or any of the codes mentioned above), in spite of the overwhelming clinical data. This too needs to be re-examined, especially as we move forward with associating payment for work “quality” and not “quantity.” 

In summary, for the patient, the future looks bright for neurosurgical pain management. This field, which was once a neurosurgical stronghold, was slowly left to the ravages of time, neglect and to the opportunistic carrion birds. It now seems that due to the blossoming field of neuromodulation, a field that is intrinsically collaborative in nature, we can pick up the pieces, and once again lead from the front. Unfortunately, there is a great deal of work that needs to be done for coding to catch up to clinical reality. In the meantime, let us continue to use these techniques and technologies for the functional restoration of our patients.


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