Deep Brain Stimulation Insurance Reimbursement Guide & Billing Codes

Your doctor and administrative assistant are critical partners in the insurance reimbursement process. Keep open and clear communications with them. As a last resort, your surgeon can speak with the medical director of the insurance company to help explain the surgery.

In Network vs. Out of Network
"In Network" vs. "Out of Network" coverage will determine the percentage of reimbursement. The hospital, anesthesiologist, surgeon, and neurologist all need to be reviewed separately to determine if they are within the insurance company's network coverage. Even if approved for an "Out of Network" procedure done at a hospital and/or doctor, the patient remains responsible for residual billing beyond what the insurance company will pay. This can be considerable.

If possible, after reviewing the insurance contract and finding it inadequate, individuals might consider changing policies to make reimbursement for DBS surgery easier. (For example, HMOs with less experienced surgeons that force members to only have the surgery done "In Network.")

Why Go Out of Network?

• The surgeon is not recognized as having adequate experience in performing DBS for dystonia

• The hospital is not equipped to support state-of-the-art surgical procedures and follow-up care in case of complications

• If approval for 'Out of Network' is granted, reimbursement will be based on the "usual and customary" fees of the community that the insured resides in

Patient Responsibilities:
1.Understand contract coverage
2.Keep accurate records of all communications, date, time, person, phone numbers, actions to be taken
3.Begin the reimbursement process three months in advance of surgery
4.Learn "CPT" codes (billing codes) approved by insurance company

Keep this in mind: DBS surgery is most often a two-stage surgery. There are two implants and two IPG's (Internal Pulse Generators and batteries). All insurance companies use the same codes for identification and reimbursement as follows:

First Surgery: Implants of Electrodes (Inpatient Hospital)
Code #61867 - This is the approval code for reimbursement for 1st implant only
Code #61868 - This is the approval code for reimbursement for 2nd implant done on the same day as the first

Second Surgery: Generator Implantation or Battery Change (Outpatient Hospital)
Code # 61885 - Single battery
Code #61885-50  - Two batteries (bilateral)

Additional Approvals Needed:
1. Surgeon: pre- and post-operation visits
2. Neurologist: for programming and continuous visits (outpatient/office visits)
    -Programming is a procedure with a CPT code 95978 for first hour, 95979 for second hour:
    -Evaluation and Management CPT code: 99211, 99212, 99213, 99214, 99215

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