For patients with moderate to severe chronic pain in the trunk or limbs, spinal cord stimulation has been shown to yield significant long-term results, including a reduction in narcotic intake and improvement in patient activity levels and quality of life. If you're already doing pain cases at your facility, adding spinal cord stimulation should be relatively easy. It doesn't require an additional capital equipment purchase, it's not a very labor-intensive procedure and if the patient has appropriate insurance coverage, the considerable costs associated with the device are covered. Spinal cord stimulation is a delicate procedure that requires the coordination of physicians, careful patient selection, and management and close attention to detail from your coders.

Patient selection
Almost all insurers require patients to undergo a psychological evaluation before they'll authorize you to implant a permanent lead for neuromodulation. Careful patient selection is key to a successful implantation, and it requires the cooperation of the referring physician, pain doctor and a psychologist.

Give all patients a trial lead placement before you green-light them for permanent implantation. The trial is relatively easy and inexpensive to do. First, patients receive monitored anesthesia care and local anesthesia. The pain doctor or surgeon will insert a percutaneous lead, similar to an epidural, which is attached to an external pulse generator, the "brain" of the stimulator. As long as the physician places the lead at the appropriate level, the pulse generator should send an electrical signal through the lead to the spinal nerves that cover the area that's painful to produce a soothing and comfortable feeling. The goal is to reduce the patient's pain by 50%, not eliminate it. Once the temporary lead is in place, the patient goes home and uses the device for several days, then comes back to have it removed.

Be sure patients get an honest and ethical evaluation during the trial period, which should show that stimulation both significantly reduced the patient's pain and improved function, meaning it let the patient do things he couldn't do before. If those criteria are met and you consider the patient a good candidate for permanent implantation, you move to the next step, which is authorization and payment for the permanent implantation, and decisions about how and where to place the permanent leads.

Permanent implantation
The permanent implantation can be done by percutaneous placement or mini-laminotomy. There's controversy over which method of lead placement is most efficacious. Here's a breakdown.

• Percutaneous. This procedure doesn't require a surgeon; a pain doctor can perform it with minimal staff and an anesthesiologist to administer monitored sedation. For permanent implantation, the doctor makes a small, 5cm-to-7cm longitudinal incision over the spine. Once the lead has been placed in an appropriate location and the patient confirms that stimulation is covering the painful area, the physician anchors the lead. Using a tunneling device, he connects the lead to the pulse generator, which is placed through a separate 3cm incision. The location of the pocket site for the pulse generator is based patient preference and body habitus. The lower posterior abdominal wall and the chest wall are common sites. The pocket should be deep enough to avoid skin erosion, about 3cm to 4cm, and away from the beltline and bony landmarks. Good communication between the pulse generator and telemetry is essential.
• Laminotomy: This method is more costly because it requires both a surgeon and a pain doc to be present, and it also involves more time, labor and equipment. The biggest expense associated with this procedure is the implantable pulse generator, which ranges in price from about $10,000 to $20,000. The surgeon tunnels down to the vertebrae, exposing the epidural space over the spinal cord. He then places a paddle-type lead under direct vision. The patient is deeply sedated and awakened once the lead is placed so the device can be tested for coverage. If the stimulator doesn't have the desired effect, the lead is repositioned until stimulation coverage is adequate.

Some doctors keep laminotomy patients for 23 hours or hospitalize them overnight. In either case, a representative from the device manufacturer is there while you place the generator and leads. The rep programs the generator, teaches the patient how to use it and follows up with the patient post-operatively to make sure he's using the device properly.

Although it's a relatively simple procedure, implanting neuromodulation devices has about a 30% complication rate. Potential complications include device malfunction and breakage, lead migration, nerve irritation and superficial infection. Proper patient selection, pre-op education and assessment, and sterile technique — including the administration of antibiotics to the patient both during the trial period and permanent implantation — can reduce the number of complications.

Getting paid
Make sure patients on private insurance have the appropriate coverage for the device. Third-party payors are very selective about whom they'll authorize for this procedure. The Neuromodulation Therapy Access Coalition (www.neuromodulationaccess.org) is working hard to give more patients access to this effective treatment.

Medicare's payment rates for ASCs shine favorably on this procedure, making it potentially profitable to do in both the surgery center and hospital settings. Medicare's ASC payment rates for spinal cord stimulation are at around 90% of the Hospital Outpatient Prospective Payment System rate, since CMS only discounts the labor portion of the procedure and fully pays for the device costs. To be paid for the leads and the implantable pulse generator, your coders will need to include the costs for these items, along with the procedure costs, in the line item charge for the CPT code. Don't list device costs separately.