CODING TIPS AND TRICKS: Coding for Posterior Tibial Nerve Technologies
By: Jonathan Rubenstein, MD, FACS | Posted on: 01 Jul 2022
The posterior tibial nerve can be accessed near the medial malleolus. Stimulation of this nerve inhibits bladder overactivity due to the activation of the sacral and central pontine micturition centers, which then send inhibitory signals to the bladder. There are a number of current and emerging technologies focused on the stimulation of the posterior tibial nerve for this indication. This article describes some of the currently available posterior tibial nerve stimulation technologies and the Current Procedural Terminology (CPT®) codes available, along with coding recommendations in the absence of specific CPT codes. Please note this is not an exhaustive list of all technologies, and the coding advice is based upon the available information at the time of publication.
Nonimplanted Technology: PTNS
Description: Posterior tibial nerve stimulation (PTNS) involves the insertion of a specialized needle near the posterior tibial nerve, which is then connected to a neuromodulation system. The nerve is typically stimulated for 30 minutes, after which the needle is removed. Therapy is typically once a week for 12 weeks, with maintenance PTNS performed as necessary.
Coding: One session of PTNS is reported using CPT code 64566, Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming. This CPT code is a zero-day global procedure, meaning that associated evaluation and management services (such as checking in on the patient and clearing the patient for the procedure that day) are included in payment and should not be reported separately. PTNS has a personal supervision designation, meaning the performing provider must be present in the room at the time of the needle placement. PTNS is covered by Medicare when meeting appropriate criteria and with coverage limitations, while coverage varies among commercial insurers. Providers should check a patient’s insurance coverage and plan benefits and limitations prior to performing PTNS.
Implanted Technologies with CPT Codes: Protect PNS
Description: Protect PNS (Uro Medical, Boca Raton, Florida), is an experimental device consisting of a nerve stimulator with embedded receiver, which is implanted percutaneously near the posterior tibial nerve. The energy source is a small, external, rechargeable transmitter, which is worn by the patient near the implant. The system uses an open-loop system, which implies the energy which is given from the wearable device to the electrode is stable but not secondarily monitored by the external unit. Patients typically use the implant for stimulation during the night, with a maximum treatment durability of 8 hours.
Coding: There are 4 Category III (emerging technology) codes associated with this device despite it not yet being commercially available: CPT 0587T, Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming and imaging guidance when performed, posterior tibial nerve; CPT 0588T, Revision or removal of integrated single device; and the 2 programming codes, 0589T, Electronic analysis with simple programming of implanted integrated neurostimulation, 1–3 parameters, and 0590T, Electronic analysis... 4 or more parameters. Parenthetical notes should be evaluated to determine what can and cannot be billed at the same time as Protect PNS placement or replacement; for example, it instructs one not to report 0587T in conjunction with 64555, 64566, 64575, 64590, 95970, 95971, 95972, 0588T, 0589T or 0590T.
Implanted Technologies without Specific CPT Codes
Description: eCoin (Valencia Technologies, Valencia, California) is a fully implanted, leadless, nickel-sized and -shaped neuromodulation device, that is U.S. Food and Drug Administration approved for the treatment of urinary urge incontinence and is currently available. The eCoin implantation procedure typically is performed in office under local anesthesia and typically takes 20–30 minutes. The eCoin itself is both a battery and stimulator so it does not require an external power source, but is programmed using an external controller. It is typically programmed to provide 30-minute stimulation treatment sessions every 2 days for 2 weeks and then every 15 days thereafter. Adjustments can be made between sessions for effectiveness and comfort.
Description: The RENOVA iStim™ system (BlueWind Medical, Herzliya, Israel) is a wireless, battery-free tibial nerve stimulator system consisting of the implant itself and an external control unit. The implant is a receiver that is capable of delivering electrical pulses and is fixed near the posterior tibial nerve below the fascia using an open surgical approach. The external control unit provides the implant with the energy needed (closed-loop system) for treatment and allows the patient to adjust the amplitude in a range between the minimum and maximum tolerable level set by the clinician. Patients wear the external control unit only during treatment sessions. This device is currently experimental and not yet commercially available.
Description: The Bioness StimRouter (Bioventus, Durham, North Carolina) is a neuromodulation system used for chronic pain that is experimental for overactive bladder. It consists of an implanted lead containing a receiver, electrodes and anchoring system, and is implanted percutaneously. It is transcutaneously powered by an external pulse transmitter. It is approved for chronic pain but also has been used for overactive bladder, mainly in Europe. Patients wear the external pulse transmitter on the skin during stimulation of the nerve, and a patient programmer can be used to change parameter settings and track usage.
Other and Emerging Devices
There are other tibial nerve devices in various stages of approval which are beyond the scope of this article at the time of publication.
Coding: For procedures that do not have a specific CPT code, the CPT codebook instructs providers to select and report an unlisted CPT code and not to select a CPT code that merely approximates the service provided. At the time of this publication, there has been no coding advice published by CPT that describes the appropriateness of a specific Category I or III CPT code use for implanted tibial nerve other than that described above. The most appropriate unlisted CPT code to choose for posterior tibial nerve technologies is CPT code 64999 Unlisted procedure, nervous system. As always it is important to check with a patient’s insurance for proper code choice and payment policy.