Deep Brain Stimulator (DBS) and Intracranial Responsive Neurostimulator (RNS) Lead Insertion
Key Terms:
- DBS Lead(s)
- RNS Lead(s)
Indications and Associated Pathology:
Deep Brain Stimulation (DBS) and Responsive Neurostimulation (RNS) are used to treat various neurological and psychiatric conditions, including:
- Localization-related (focal) (partial) idiopathic or symptomatic epilepsy
- Essential tremor
- Intractable dystonias
- Meige syndrome
- Multiple sclerosis
- Obsessive-compulsive disorder (OCD)
- Parkinson’s disease
Overview:
DBS and RNS devices are designed to modulate brain activity and provide therapeutic benefits in patients with specific neurological conditions. These devices consist of a generator connected to electrodes (leads) that are implanted into the brain. The electrodes are placed in specific regions of the brain based on the condition being treated, such as the thalamus for tremors or the cortical areas for epilepsy.
- Deep Brain Stimulation (DBS): Primarily used for controlling tremors, dystonias, and movement disorders like Parkinson’s disease.
- Responsive Neurostimulation (RNS): Specifically aimed at treating adults with medically refractory localization-related (focal) epilepsy.
Both devices deliver electrical impulses through the leads to the targeted brain areas, which may help reduce symptoms like tremors or seizures.
Procedure for Lead Insertion:
The process of inserting the neurostimulator lead involves the following steps:
- Preparation: The surgeon accesses the brain through different approaches, depending on the targeted area for lead placement. These approaches may include:
- Twist drill
- Burr holes
- Craniectomy or craniotomy (removal of a portion of the skull)
- Lead Placement:
- Open approach: If the brain is directly visualized, such as through a craniotomy, the procedure is considered “open.”
- Percutaneous approach: If the lead is inserted with the help of a small burr hole, guided by imaging techniques without directly visualizing the brain, the approach is “percutaneous.”
- Electrode Placement: Once the appropriate brain area is reached, the electrode (lead) is inserted into the target location. The placement is verified by sending electrical impulses through the lead to ensure its proper position.
- Device Connection: The electrode is connected to the neurostimulator generator via extension wires, which are tunneled under the skin.
- Completion: Once the electrode is in place and functioning correctly, the surgeon replaces any bone removed during the procedure and closes the incisions, ensuring that no part of the device or wires is exposed outside the body.
- Device Reporting: The device used for lead placement is referred to as a neurostimulator lead.
Focus Areas:
- For generator insertion (whether DBS or RNS), refer to specific procedures such as DBS Generator Insertion or Intracranial RNS Generator Insertion.
Body Systems Involved:
- Central Nervous System (CNS)
- Cranial Nerves
Root Operation:
- Insertion: This refers to the process of placing a non-biological appliance (the neurostimulator lead) that monitors, assists, or prevents physiological functions without replacing a body part.
Body Part Involved:
- Brain
- Cerebral Ventricle
Approaches:
- Open: Direct visualization of the brain during the procedure (e.g., craniotomy).
- Percutaneous: The lead is inserted via a small burr hole using imaging techniques.
Device:
- Neurostimulator Lead: The lead implanted in the brain to deliver electrical impulses from the generator.
Coding and Compliance:
- Single Array Generator: This generator is connected to a single lead and can be used unilaterally. If multiple leads are implanted, a Multiple Array Generator is used.
- Lead Coding: Each lead placed through a separate site is coded individually.
- Responsive Neurostimulator (RNS): The RNS generator is typically connected to one or two leads that are implanted in the brain (either as a depth lead or a cortical strip lead).
- DBS System: The leads in DBS are placed deeply within the brain, and the generator is implanted subcutaneously.
- Approach for Lead Insertion: If the lead is inserted via burr holes, the approach is classified as percutaneous as per the 3rd Quarter 2017 Coding Clinic.
Associated Procedures:
Commonly performed alongside the lead insertion procedure are:
- Brain Mapping (Cortical): Mapping brain activity to guide precise lead placement.
- Computer-Assisted Surgery: Use of advanced technology to enhance precision in surgery.
- DBS Generator Insertion: The process of inserting the generator connected to the DBS lead.
- RNS Generator Insertion: The procedure for placing the generator that works with the RNS lead.
- Stereotactic Head Frame: A device used to accurately position the brain during the procedure.
Reimbursement Information:
Reimbursement is based on the complexity of the procedure, which may involve different categories:
- Single Array Generator Insertion:
- MS-DRG 025 – 027: Craniotomy and Endovascular Procedures with or without major complications.
- Codes:
- 0JH[6,7,8][0,3][B,C]Z: Insertion of Stimulator Generator (Single Array)
- 00H0*MZ: Insertion of Neurostimulator Lead into the brain
- 00H6*MZ: Insertion of Neurostimulator Lead into the cerebral ventricle
- Multiple Array Generator with Leads:
- MS-DRG 023 – 024: Craniotomy with Major Device Implant for acute CNS principal diagnosis or epilepsy.
- Codes:
- 0JH[6,7,8][0,3][D,E]Z: Insertion of Stimulator Generator (Multiple Array)
- 00H0*MZ: Insertion of Neurostimulator Lead into the brain
- 00H6*MZ: Insertion of Neurostimulator Lead into the cerebral ventricle
- Neurostimulator Generator Skull Insertion with Leads:
- MS-DRG 023: Craniotomy with Major Device Implant for acute CNS principal diagnosis, chemotherapy implant, or epilepsy with or without major complications.
- Codes:
- 0NH00NZ: Insertion of Neurostimulator into Skull Bone
- 00H0*MZ: Insertion of Neurostimulator Lead into the brain
- 00H6*MZ: Insertion of Neurostimulator Lead into the cerebral ventricle
This structured approach ensures clarity in procedure coding, facilitating the correct reimbursement and regulatory compliance for these complex interventions.