Neuros mula on Therapy FOR CHRONIC PAIN Trunk and/or Limbs

Transcription

1 FOR CHRONIC PAIN Trunk and/or Limbs Commonly Billed Codes Effec ve January 2015 Medtronic provides this informa on for your convenience only. It is not intended as a recommenda on regarding clinical prac ce. It is the responsibility of the provider to determine coverage and to submit appropriate codes, modifiers, and charges for the services rendered. This document provides assistance for FDA approved or cleared indica ons. Where reimbursement is requested for a use of a product that may be inconsistent or not expressly specified in the FDA cleared or approved labeling (e.g., instruc ons for use, operator s manual, or package insert) consult with your billing advisors or payers for advice on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service. Contact your Medicare contractor or other payer for interpreta on of coverage, coding, and payment policies. The following informa on is calculated per the footnotes included and does not take into effect Medicare payment reduc ons resul ng from sequestra on associated with the Budget Control Act of Sequestra on reduc ons went into effect on April 1, ICD 9 CM 1 Diagnosis Codes Diagnosis codes are used by both physicians and hospitals to document the indica on for the procedure. Pain codes from the 338 series are used as the principal diagnosis when the encounter is for pain control or pain management, rather than for management of the underlying condi on. Neuros mula on Therapy is directed at managing chronic, intractable pain rather than trea ng the underlying disorder. When a pa ent is admi ed for inser on of a neuros mulator for pain control, the pain code is sequenced as the principal diagnosis. Addi onal codes may then be assigned to iden fy the underlying cause as well to give more detail about the nature and loca on of the pain. Note that when the encounter is for a procedure aimed at trea ng the underlying condi on and a neuros mulator is also inserted for pain control, the underlying disorder is assigned as the principal diagnosis. However, an encounter specifically to insert a neuros mulator is most common. Chronic Pain Disorders Central pain syndrome Other chronic pain Chronic pain syndrome Note: Pain must be specifically documented as chronic to use code Similarly, the diagnos c term chronic pain syndrome must be specifically documented to assign code If these terms are not documented, then other symptom codes for pain may be assigned instead. However, they cannot be sequenced as principal diagnosis. Rather, the underlying condi on would ordinarily be used as the principal diagnosis in this circumstance. Reflex Sympathe c Dystrophy and Causalgia Reflex sympathe c dystrophy of the upper limb (complex regional pain syndrome type I of upper limb) Reflex sympathe c dystrophy of the lower limb (complex regional pain syndrome type I of lower limb) Causalgia of upper limb (complex regional pain syndrome type II of upper limb) Causalgia of lower limb (complex regional pain syndrome type II of lower limb) Note: Complex regional pain syndrome not specified as type l or type ll defaults to causalgia. Codes from the 338 series should not be assigned with causalgia or reflex sympathe c dystrophy because pain is a known component of these disorders. Commonly Billed Codes For ques ons please contact us at neuro.us.reimbursement@medtronic.com

2 ICD 9 CM 1 Diagnosis Codes con nued Underlying Causes of Chronic Pain Arachnoidi s, chronic Arachnoidi s, other and unspecified Epidural fibrosis Peripheral neuropathy of upper limb Peripheral neuropathy of lower limb Radiculi s due to herniated disc, lumbar Radiculi s due to degenera ve disc disease, lumbar Postlaminectomy syndrome, lumbar region (failed back syndrome) Radicular syndrome of upper limbs (not due to disc hernia on or degenera on) Radicular syndrome of lower limbs (not due to disc hernia on or degenera on) A en on to Device 2 V53.02 Fi ng and adjustment of neuropacemaker (brain, peripheral nerve, spinal cord) ICD 9 CM 1 Procedure Codes Hospitals use ICD 9 CM 1 procedure codes for inpa ent services. Lead Inser on or Replacement Implanta on or replacement of spinal neuros mulator lead(s) Generator Implanta on or Replacement Inser on or replacement of single array neuros mulator pulse generator, not specified as rechargeable Inser on or replacement of mul ple array neuros mulator pulse generator, not specified as rechargeable Inser on or replacement of single array rechargeable neuros mulator pulse generator Inser on or replacement of mul ple array (two or more) rechargeable neuros mulator pulse generator 3 Lead Removal Removal of spinal neuros mulator lead(s) Generator Removal Incision with removal of foreign body or device from skin and subcutaneous ssue Other Revision Other opera on on spinal cord and spinal canal structures Other incision of skin and subcutaneous ssue 1. The Interna onal Classifica on of Diseases, Ninth Revision, Clinical Modifica on (ICD 9 CM) is maintained by the Na onal Center for Health Sta s cs and the Centers for Medicare and Medicaid Services. (U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Interna onal Classifica on of Diseases, Ninth Revision, Clinical Modifica on (ICD 9 CM). h p:// Accessed November 11, 2014.) 2. Code V53.02 is used as the principal diagnosis when pa ents are seen for rou ne device replacement and maintenance. A secondary diagnosis code is then used for the underlying condi on. 3. Codes and include dual array neuros mulator pulse generators, a type of mul ple array generator in which two leads are connected to one generator. 4. Code should be reserved for surgical revision of leads within the spinal canal, eg. reposi oning, while should be used for subcutaneous revisions, eg. reconnec ng to the generator. Code can also be assigned for other subcutaneous procedures such as opening the pocket for generator revision, reloca ng the device pocket while reinser ng the same generator, and revising an extension. Commonly Billed Codes 2

3 HCPCS II Device Codes 1 These codes are u lized by the en ty that purchased and supplied the medical device, DME, drug, or supply to the pa ent. For implantable devices, that is generally the facility. It may also be the physician, most commonly for trial leads placed in the office. For specific Medicare hospital outpa ent instruc ons for medical devices, see the Device C Codes for Medicare. Lead 2 L8680 Implantable neuros mulator electrode, each Pulse Generator 3 Note: Effec ve January 2014, codes L8685 L8688 are not payable by Medicare. L8679 L8685 L8686 L8687 L8688 Implantable neuros mulator pulse generator, any type Implantable neuros mulator pulse generator, single array, rechargeable, includes extension Implantable neuros mulator pulse generator, single array, non rechargeable, includes extension Implantable neuros mulator pulse generator, dual array, rechargeable, includes extension Implantable neuros mulator pulse generator, dual array, non rechargeable, includes extension External Recharger L8689 External recharging system for ba ery (internal) for use with implantable neuros mulator, replacement only Pa ent Programmer L8681 Pa ent programmer (external) for use with implantable programmable neuros mulator pulse generator, replacement only 1. Healthcare Common Procedure Coding System (HCPCS) Level II codes are maintained by the Centers for Medicare and Medicaid Services. (Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System (HCPCS) Level II. h p:// Accessed November 11, 2014) 2. Physicians should not submit code L8680 to Medicare for leads placed in the office. This code is not separately billable to Medicare because the cost of the lead is already valued in the CPT procedure code. (Centers for Medicare and Medicaid Services. MLN Ma ers Number MM8645. h p:// and Educa on/medicare Learning Network MLN/ MLNMa ersar cles/downloads/mm8645.pdf. Accessed November 11, 2014.) Code L8680 remains available for use with non Medicare payers, though physicians should check with the payer for specific coding and billing instruc ons. Likewise, hospitals and ASCs may be able to submit L8680 for non Medicare payers but should check with the payer for instruc ons. 3. Effec ve January 2014, generator codes L8685 L8688 are not payable by Medicare. Specifically for billing Medicare, code L8679 is available for physician use, while hospitals typically use C codes and ASCs generally do not submit HCPCS II codes for devices. For non Medicare payers, codes L8685 L8688 remain available. However, all providers should check with the payer for specific coding and billing instruc ons. Device C Codes 1 (Medicare) Medicare provides C codes for hospital use in billing Medicare for medical devices in the outpa ent se ng. Although other payers may also accept C codes, regular HCPCS II device codes are generally used for billing non Medicare payers. Unlike regular HCPCS II device codes, the extension is separately codable using C codes. ASCs, however, usually should not assign or report HCPCS II device codes for devices on claims sent to Medicare. Medicare generally does not make a separate payment for devices in the ASC. Instead, payment is packaged into the payment for the ASC procedure. ASCs are specifically instructed not to bill HCPCS II device codes to Medicare for devices that are packaged. 2 Pulse Generator (non rechargeable) Pulse Generator (rechargeable) Extension Leads Pa ent Programmer C1767 Generator, neuros mulator (implantable) non rechargeable C1820 Generator, neuros mulator (implantable) with rechargeable ba ery and charging system C1883 Adaptor/extension, pacing lead or neuros mulator lead (implantable) C1778 Lead, neuros mulator (implantable) C1897 Lead, neuros mulator, test kit (implantable) C1787 Pa ent programmer, neuros mulator 1. Device C codes are HCPCS Level II codes and also maintained by the Centers for Medicare and Medicaid Services. (Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System. h p:// Numeric HCPCS.html. Accessed November 11, 2014) 2. ASCs should report all charges incurred. However, only charges for non packaged items should be billed as separate line items. For example, the ASC should report its charge for the generator. However, because the generator is a packaged item, the charge should not be reported on its own line. Instead, the ASC should bill a single line for the implanta on procedure with a single total charge, including not only the charge associated with the opera ng room but also the charges for the generator and all other packaged items. Because of a Medicare requirement to pay the lesser of the ASC rate or the line item charge, breaking these packaged charges out onto their own lines can result in incorrect payment to the ASC. (See the Medicare Claims Processing Manual, Chapter 14, Sec on 40; see also MLN Ma ers SE0742 p.9 10). (Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14 Ambulatory Surgical Centers. h p:// ons and Guidance/Guidance/Manuals/downloads/clm104c14.pdf. Accessed November 11, 2014.) (Centers for Medicare and Medicaid Services. MLN Ma ers Number SE0742 Revised. h p:// and Educa on/medicare Learning Network MLN/ MLNMa ersar cles/downloads/se0742.pdf. Accessed November 11, 2014.) Commonly Billed Codes 3

4 Device Edits (Medicare) 1 Medicare s procedure to device edits require that when certain CPT procedure codes for device implanta on are submi ed on a hospital outpa ent bill, HCPCS II codes for devices must also be billed. Effec ve January 2015, the edits are broadly defined and may include any HCPCS II device code with any CPT procedure code used in earlier versions of the edits. 2 Within this context, the HCPCS II device codes shown below are both appropriate for the CPT procedure codes and will pass the edits. CPT Procedure Code CPT Code Descrip on Percutaneous implanta on of neuros mulator electrode array, epidural ,5 Laminectomy for implanta on of neuros mulator electrodes, plate/paddle, epidural Inser on or replacement of spinal neuros mulator pulse generator or receiver, direct or induc ve coupling HCPCS II Device Codes C1778 C1897 C1778 C1767 C1820 HCPCS II Code Descrip on Lead, neuros mulator (implantable) Lead, neuros mulator, test kit (implantable) Lead, neuros mulator (implantable) Generator, neuros mulator (implantable), non rechargeable Generator, neuros mulator (implantable), with rechargeable ba ery and charging system 1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpa ent Prospec ve Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg h ps://federalregister.gov/a/ Published November 10, Accessed November 11, Centers for Medicare & Medicaid Services. Device and Procedure Edits. h ps:// Fee for Service Payment/HospitalOutpa entpps/ device_procedure.html. Accessed November 11, CPT copyright 2014 American Medical Associa on. All rights reserved. CPT is a registered trademark of the American Medical Associa on. No fee schedules, basic units, rela ve values, or related lis ngs are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restric ons apply to government use. 4. HCPCS II code L8680 will also pass the edits with CPT procedure codes and 63655, but this code is not shown because it is not otherwise recognized by Medicare. 5. HCPCS II device code C1897 will pass the edits with CPT procedure code In prac ce, however, HCPCS device code C1897 is not appropriate with CPT procedure code because this type of kit is not currently used when tes ng is performed via laminectomy. 6. HCPCS II device codes L8686 L8688 for various generator types will also pass the edits with CPT procedure code 63685, but these codes are not shown because they are not otherwise recognized by Medicare. HCPCS II device code L8679 does not sa sfy the edits. Commonly Billed Codes 4

5 Physician Coding and Payment January 1, 2015 March 31, 2015 CPT Procedure Codes Physicians use CPT codes for all services. Under Medicare s Resource Based Rela ve Value Scale (RBRVS) methodology for physician payment, each CPT code is assigned a point value, the rela ve value unit (RVU), which is then converted to a flat payment amount. Procedure CPT Code and Descrip on 1 Medicare RVUs 2 Medicare Na onal Average 3 For physician services provided in: 4 Physician Facility Physician Office 5 Office 5 Facility Screening Test 6,7,8 Lead Implanta on 6,7,8 Generator Implanta on or Replacement 7,11 Removal of Leads 7,12,13,14 Revision or Replacement of Leads 7,13,14 Revision or Removal of Generator 7, Percutaneous implanta on of neuros mulator $1,350 $425 electrode array, epidural 9, Laminectomy for implanta on of neuros mulator electrodes, plate/paddle, epidural N/A N/A $ Percutaneous implanta on of neuros mulator $1,350 $425 electrode array, epidural 9, Laminectomy for implanta on of neuros mulator electrodes, plate/paddle, epidural Inser on or replacement of spinal neuros mulator pulse generator or receiver, direct or induc ve coupling Removal of spinal neuros mulator electrode percutaneous array(s), including fluoroscopy, when performed Removal of spinal neuros mulator electrode plate/paddle(s) placed via laminotomy or laminectomy, Including fluoroscopy, when performed Revision including replacement, when performed, of spinal neuros mulator electrode percutaneous array(s), including fluoroscopy when performed Revision including replacement, when performed, of spinal neuros mulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy when performed Revision or removal of implanted spinal neuros mulator pulse generator or receiver N/A N/A $865 N/A N/A $ $591 $332 N/A N/A $ $803 $466 N/A N/A $896 N/A N/A $384 Commonly Billed Codes 5

6 Physician Coding and Payment con nued Procedure Analysis/ Programming Note: In the office, analysis and programming may be furnished by a physician, prac oner with an incident to benefit, or auxiliary personnel under the direct supervision of the physician (or other prac oner), with or without support from a manufacturer s representa ve. The pa ent or payer should not be billed for services rendered by the manufacturer s representa ve. Contact your local contractor or payer for interpreta on of applicable policies. CPT Code and Descrip on Electronic analysis of implanted neuros mulator pulse generator system (e.g., rate, pulse amplitude, pulse dura on, configura on of wave form, ba ery status, electrode selectability, output modula on, cycling, impedance, and pa ent compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neuros mulator pulse generator/ transmi er, without reprogramming Electronic analysis of implanted neuros mulator pulse generator system (e.g., rate, pulse amplitude, pulse dura on, configura on of wave form, ba ery status, electrode selectability, output modula on, cycling, impedance, and pa ent compliance measurements); simple spinal cord or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) neuros mulator pulse generator/transmi er, with intraopera ve or subsequent programming Electronic analysis of implanted neuros mulator pulse generator system (e.g., rate, pulse amplitude, pulse dura on, configura on of wave form, ba ery status, electrode selectability, output modula on, cycling, impedance, and pa ent compliance measurements); complex spinal cord or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neuros mulator pulse generator/transmi er, with intraopera ve or subsequent programming, up to 1 hour 15, Electronic analysis of implanted neuros mulator pulse generator system (e.g., rate, pulse amplitude, pulse dura on, configura on of wave form, ba ery status, electrode selectability, output modula on, cycling, impedance, and pa ent compliance measurements); complex spinal cord or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neuros mulator pulse generator/transmi er, each addi onal 30 minutes a er first hour (List separately in addi on to code for primary procedure) Medicare RVUs 2 Medicare Na onal Average 3 For physician services provided in: 4 Physician Facility Physician Office 5 Office 5 Facility $68 $ $58 $ $56 $ $41 $26 Commonly Billed Codes 6

7 Physician Coding and Payment con nued 1. CPT copyright 2014 American Medical Associa on. All rights reserved. CPT is a registered trademark of the American Medical Associa on. No fee schedules, basic units, rela ve values, or related lis ngs are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restric ons apply to government use. 2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule 79 Fed. Reg h ps://federalregister.gov/a/ Published November 13, Accessed November 17, The total RVU as shown here is the sum of three components: physician work RVU, prac ce expense RVU, and malprac ce RVU. 3. Medicare na onal average payment is determined by mul plying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $ through March 31, 2015 in accordance with the CMS 1612 FC, Centers for Medicare & Medicaid Services PFS Rela ve Value File (January Release). h p:// Fee for Service Payment/PhysicianFeeSched/Downloads/CY2015 PFS FR RVU.zip. Published December 30, Accessed January 5, Final payment to the physician is adjusted by the Geographic Prac ce Cost Indices (GPCI). Also note that any applicable coinsurance, deduc ble, and other amounts that are pa ent obliga ons are included in the payment amount shown. 4. The RVUs shown are for the physician s services and payment is made to the physician. However, there are different RVUs and payments depending on the se ng in which the physician rendered the service. Facility includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the Facility se ng because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the Physician Office se ng because the physician incurs all costs there. 5. N/A shown in Physician Office se ng indicates that Medicare has not developed RVUs in the office se ng because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate. Centers for Medicare & Medicaid Services. Details for Title: CMS 1612 FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explana on of Addendum B and C. h p:// Fee for Service Payment/ PhysicianFeeSched/PFS Federal Regula on No ces Items/CMS 1612 FC.html. Published November 13, Accessed November 17, As defined and as published by the AMA (CPT Assistant, June 1998, p.4), these codes represent a single lead. When more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier 50 or L T/ RT on these codes. Some payers recognize that each code represents a dis nct lead when modifier 51 or modifier 59 is appended to the addi onal codes. Note that Medicare s Medically Unlikely Edits allow 2 units for code on the same date of service, but only 1 unit for code Denials for units in excess of the MUE values may be appealed. 7. Surgical procedures are subject to a global period. The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed or paid when rendered by the physician who performed the surgery. These services include: preopera ve visits the day before or the day of the surgery, postopera ve visits related to recovery from the surgery for 10 or 90 days depending on the specific procedure, treatment of complica ons unless they require a return visit to the opera ng room, and minor postopera ve services such as dressing changes and suture removal. 8. The published vigne es for codes and include fluoroscopy and, according to guidelines published by the American Associa on of Neurological Surgeons (AANS Guide to Coding, 2012 Edi on, p.66), its use is inherent to lead implanta on and should not be coded separately. In addi on, Na onal Correct Coding Ini a ve (NCCI) edits prohibit coding fluoroscopy separately with and The Physician Office RVUs for code are valued to include payment for the lead and other prac ce expenses associated with office based trials. HCPCS code L8680 should not be reported separately for the lead in conjunc on with office based trials. 10. The AMA has published (CPT Assistant, October 2013, p.19) that use of an incision to admit the needle or to anchor the lead is inherent to percutaneous placement and does not alter use of code When an exis ng generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the exis ng generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator inser on or replacement requires placement of a new generator. When the same generator is removed and then re inserted, the revision code is used. 12. The AMA has published that the work of removing a temporary trial lead is inherent to the original percutaneous placement code and is not coded separately. Code cannot be assigned for removal of a temporary trial lead that was placed percutaneously. Further, codes and apply to surgical removal of permanent leads. Removal of a permanent lead by simple pull is not coded (CPT Assistant, August 2010, p.8,15; April 2011,p.10 11,15). 13. The AMA has published that replacement codes and are assigned when a permanent lead is replaced by another permanent lead of the same type via the same approach at the same spinal level. The work of removing the exis ng permanent lead is included and is not coded separately (CPT Assistant, August 2010, p.8,15; April 2011,p.10 11,15). 14. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, inser on code is assigned with removal code (CPT Assistant, April 2011,p.11,15). NCCI edits allow this combina on without use of a modifier. 15. According to CPT manual instruc ons, simple programming involves changes to three or fewer parameters and complex programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse dura on, pulse frequency, eight or more electrode contacts, cycling, s mula on train dura on, train spacing, number of programs, number of channels, alterna ng electrode polari es, dose me (s mula on parameters changing in me periods of minutes including dose lockout mes), more than one clinical feature. 16. According to CPT manual instruc ons, append modifier 52 for reduced services to code if complex programming lasts less than 31 minutes. Commonly Billed Codes 7

8 Hospital Outpa ent Coding and Payment Effec ve January 1, 2015 December 31, 2015 CPT Procedure Codes Hospitals use CPT codes for outpa ent services. Under Medicare s APC methodology for hospital outpa ent payment, each CPT code is assigned to one of approximately 765 ambulatory payment classes. Each APC has a rela ve weight that is then converted to a flat payment amount. Mul ple APCs can be assigned for each encounter, depending on the number of procedures coded and whether any of the procedure codes map to a Comprehensive APC. New! Comprehensive APCs ǂ Effec ve January 1, 2015, CMS has designated 25 APCs as Comprehensive APCs (C APCs). Each CPT procedure code assigned to one of these C APCs is considered a primary service, and all other procedures and services coded on the bill are considered adjunc ve to delivery of the primary service. This results in a single APC payment and a single beneficiary copayment for the en re outpa ent encounter, based solely on the primary service. Separate payment is not made for the other adjunc ve services. Instead, the payment level for the C APC is calculated to include the costs of the other adjunc ve services, which are packaged into the payment for the primary service. When more than one primary service is coded for the same outpa ent encounter, the codes are ranked according to a fixed hierarchy. The C APC is then assigned according to the highest ranked code. In some special circumstances, the combina on of two primary services leads to a complexity adjustment in which the en re encounter is re mapped to another higher level APC. However, there are no complexity adjustments for neuros mula on therapy for chronic pain. As shown on the tables below, neuros mula on therapy for chronic pain is subject to C APCs specifically for implanta on and revision/replacement of the leads, and inser on/replacement of the generator. C APCs are iden fied by status indicator J1. Procedure CPT Code and Descrip on 1 APC 2 APC Title 2 SI 2,3 Rela ve Weight 2 Screening Test 5, Percutaneous implanta on of neuros mulator electrode array, epidural Level II Neuros mulator Medicare Na onal Average 2,4 J $5, Laminectomy for implanta on of neuros mulator electrodes, plate/paddle, epidural 0039 Level III Neuros mulator J $17,099 Lead Implanta on 5,6, Percutaneous implanta on of neuros mulator electrode array, epidural Level II Neuros mulator J $5, Laminectomy for implanta on of neuros mulator electrodes, plate/paddle, epidural 0039 Level III Neuros mulator J $17,099 Generator Implanta on or Replacement 9, Inser on or replacement of spinal neuros mulator pulse generator or receiver, direct or induc ve coupling 0318 Level IV Neuros mulator J $26,152 ǂ Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpa ent Prospec ve Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg h ps://federalregister.gov/a/ Published November 10, Accessed November 11, Commonly Billed Codes 8

9 Hospital Outpa ent Coding and Payment con nued Procedure CPT Code and Descrip on 1 APC 2 APC Title 2 SI 2,3 Rela ve Weight 2 Removal of Leads 11,12, Removal of spinal neuros mulator electrode percutaneous array(s), including fluoroscopy when performed Medicare Na onal Average 2, Level I Nerve Procedures Q $1, Removal of spinal neuros mulator electrode plate/ paddle(s) placed via laminotomy or laminectomy, including fluoroscopy when performed 0688 Level I Neuros mulator Q $2,128 Revision or Replacement of Leads 12, Revision including replacement, when performed, of spinal neuros mulator electrode percutaneous array(s), including fluoroscopy when performed 0061 Level II Neuros mulator J $5, Revision including replacement, when performed, of spinal neuros mulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy when performed 0061 Level II Neuros mulator J $5,289 Revision or Removal of Generator Revision or removal of implanted spinal neuros mulator pulse generator or receiver 0688 Level I Neuros mulator Q $2,128 Commonly Billed Codes 9

10 Hospital Outpa ent Coding and Payment con nued Procedure CPT Code and Descrip on 1 APC 2 APC Title 2 SI 2,3 Rela ve Weight 2 Analysis and Programming Note: In the hospital, analysis and programming may be furnished by a physician or other prac oner, with or without support from a manufacturer s representa ve. Neither the payer or pa ent should be billed for services rendered by the manufacturer s representa ve. Contact your local contractor or payer for interpreta on of applicable policies Electronic analysis of implanted neuros mulator pulse generator system (e.g., rate, pulse amplitude, pulse dura on, configura on of wave form, ba ery status, electrode selectability, output modula on, cycling, impedance, and pa ent compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neuros mulator pulse generator/ transmi er, without reprogramming Electronic analysis of implanted neuros mulator pulse generator system (e.g., rate, pulse amplitude, pulse dura on, configura on of wave form, ba ery status, electrode selectability, output modula on, cycling, impedance, and pa ent compliance measurements); simple spinal cord or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) neuros mulator pulse generator/ transmi er, with intraopera ve or subsequent programming Level I Nerve and Muscle Services 0692 Level II Electronic Analysis of Devices Medicare Na onal Average 2,4 Q $95 S $ Electronic analysis of implanted neuros mulator pulse generator system (e.g., rate, pulse amplitude, pulse dura on, configura on of wave form, ba ery status, electrode selectability, output modula on, cycling, impedance, and pa ent compliance measurements), complex spinal cord or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neuros mulator pulse generator/transmi er, with intraopera ve or subsequent programming, up to 1 hour 14, Level II Electronic Analysis of Devices S $ Electronic analysis of implanted neuros mulator pulse generator system (e.g., rate, pulse amplitude, pulse dura on, configura on of wave form, ba ery status, electrode selectability, output modula on, cycling, impedance, and pa ent compliance measurements), complex spinal cord or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neuros mulator pulse generator/transmi er, each addi onal 30 minutes a er first hour (List separately in addi on to code for primary procedure) N/A N/A N N/A N/A Commonly Billed Codes 10

11 Hospital Outpa ent Coding and Payment con nued 1. CPT Copyright 2014 American Medical Associa on. All rights reserved. CPT is a registered trademark of the American Medical Associa on. No fee schedules, basic units, rela ve values, or related lis ngs are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restric ons apply to government use. 2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpa ent Prospec ve Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg h ps://federalregister.gov/a/ Published November 10, Accessed November 11, Status Indicator (SI) shows how a code is handled for payment purposes: N = packaged service, no separate payment; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher weighted T procedure; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure ; J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunc ve services. 4. Medicare na onal average payment is determined by mul plying the APC weight by the conversion factor. The conversion factor for 2015 is $ The conversion factor of $ assumes that hospitals meet repor ng requirements of the Hospital Outpa ent Quality Data Repor ng Program. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpa ent Prospec ve Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg h ps://federalregister.gov/a/ Published November 10, Accessed November 11, Payment is adjusted by the wage index for each hospital s specific geographic locality, so payment will vary from the na onal average Medicare payment levels displayed. Also note that any applicable coinsurance, deduc ble, and other amounts that are pa ent obliga ons are included in the na onal average payment amount shown. 5. As defined and as published by the AMA (CPT Assistant, June 1998, p.4), these codes represent a single lead, and when more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier 50 or L T/ RT on these codes. Some payers recognize that each code represents a dis nct lead when modifier 59 is appended to the addi onal codes. Note that Medicare s Medically Unlikely Edits allow 2 units for code on the same date of service, but only 1 unit for code Denials for units in excess of the MUE values may be appealed. 6. The published vigne es for codes and include fluoroscopy and, according to guidelines published by the American Associa on of Neurological Surgeons (AANS Guide to Coding, 2012 Edi on, p.66), its use is inherent to lead implanta on and should not be coded separately. In addi on, Na onal Correct Coding Ini a ve (NCCI) edits prohibit coding fluoroscopy separately with and The AMA has published (CPT Assistant, October 2013, p.19) that use of an incision to admit the needle or to anchor the lead is inherent to percutaneous placement and does not alter use of code When implanta on of two leads is coded and billed, ie plus , the en re encounter con nues to map to the APCs shown. Because these are C APCs and no complexity adjustment applies, there is no addi onal payment for the second lead. 9. NCCI policy does not allow removal of the exis ng generator to be coded separately. When an exis ng generator is removed and replaced by a new generator, only the generator replacement code may be assigned. Also note that, according to NCCI policy, use of the CPT code for generator inser on or replacement requires placement of a new pulse generator. When the same pulse generator is removed and then re inserted, the revision code is used. 10. When generator implanta on is coded and billed together with lead implanta on, for example plus 63650, the en re encounter con nues to map to the APC for generator implanta on. Because this is a C APC and no complexity adjustment applies, there is no addi onal payment for the lead. 11. The AMA has published that the work of removing a temporary trial lead is inherent to the original percutaneous placement code and is not coded separately. Code cannot be assigned for removal of a temporary trial lead that was placed percutaneously. Further, codes and apply to surgical removal of permanent leads. Removal of a permanent lead by simple pull is not coded (CPT Assistant, August 2010, p.8,15; April 2011,p.10 11,15). 12. The AMA has published that replacement codes and are assigned when a permanent lead is replaced by another permanent lead of the same type via the same approach at the same spinal level. The work of removing the exis ng permanent lead is included and is not coded separately (CPT Assistant, August 2010, p.8,15; April 2011,p.10 11,15). 13. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, inser on code is assigned with removal code (CPT Assistant, April 2011,p.11,15). NCCI edits allow this combina on without use of a modifier. 14. According to CPT manual instruc ons, simple programming involves changes to three or fewer parameters and complex programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse dura on, pulse frequency, eight or more electrode contacts, cycling, s mula on train dura on, train spacing, number of programs, number of channels, alterna ng electrode polari es, dose me (s mula on parameters changing in me periods of minutes including dose lockout mes), more than one clinical feature. 15. According to CPT manual instruc ons, append modifier 52 for reduced services to code if complex programming lasts less than 31 minutes. For hospital outpa ent repor ng, modifier 52 is used to indicate par al reduc on of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4 Part B Hospital, Sec on A. h p:// ons and Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Accessed November 11, Commonly Billed Codes 11

12 Hospital Inpa ent Coding and Payment Effec ve October 1, 2014 September 30, 2015 MS DRG Assignments Under Medicare s MS DRG methodology for hospital inpa ent payment, each inpa ent stay is assigned to one of about 750 diagnosis related groups, based on the ICD 9 CM codes assigned to the diagnoses and procedures. Each MS DRG has a rela ve weight that is then converted to a flat payment amount. Only one MS DRG is assigned for each inpa ent stay, regardless of the number of procedures performed. The MS DRGs shown are those typically assigned to the following scenarios. For neuros mula on therapy for chronic pain, DRG assignment varies depending on the diagnosis and the specific procedures performed. Procedure Scenario MS DRG 1 MS DRG Title 1,2 Rela ve Weight 1 Medicare Na onal Average 3 Implanta on or Replacement: Whole System Whole system implant or replacement generator ( ) plus leads (03.93) Pain disorder (338.X) or due to causalgia or RSD, and other nervous system disorders 4 Due to musculoskeletal disorders Spinal Procedures W MCC $31, Spinal Procedures W CC or Spinal Neuros mulators 518 Back and Neck Procedures Except Spinal Fusion W MCC or Disc Device/Neuros mulator $18, $17,988 Implanta on or Replacement: Generator Only Generator only implant or replacement ( ) Pain disorder (338.X) or due to causalgia or RSD, and other nervous system disorders Peripheral/Cranial Nerve and Other Nervous System Procedures W MCC 041 Peripheral/Cranial Nerve and Other Nervous System Procedures W CC or Peripheral Neuros mulator $22, $12, Peripheral/Cranial Nerve and Other Nervous System Procedures W/O CC/MCC $10,915 Due to musculoskeletal disorders Extensive OR Procedure Unrelated to Principal Diagnosis W MCC $29, Extensive OR Procedure Unrelated to Principal Diagnosis W CC $16, Extensive OR Procedure Unrelated to Principal Diagnosis W/O CC/MCC $10,594 Commonly Billed Codes 12

13 Hospital Inpa ent Coding and Payment con nued Procedure Scenario MS DRG 1 MS DRG Title 1,2 Implanta on or Replacement: Leads Only Lead only implant or replacement (03.93) Pain disorder (338.X) or due to causalgia or RSD, and other nervous system disorders 4 Rela ve FY 2015 Weight 1 Medicare Na onal Average Spinal Procedures W MCC $31, Spinal Procedures W CC or Spinal Neuros mulators 030 Spinal Procedures W/O CC/MCC $18, $10,474 Due to musculoskeletal disorders Back and Neck Procedures Except Spinal Fusion W MCC or Disc Device /Neuros mulator 519 Back and Neck Procedures Except Spinal Fusion W CC 520 Back and Neck Procedures Except Spinal Fusion W/O CC/MCC $17, $9, $6,693 Removal (without replacement) 4,8 En re system removal, generator (86.05) plus leads (03.94) Generator only removal (86.05) 028 Spinal Procedures W MCC $31, Spinal Procedures W CC or Spinal Neuros mulators 030 Spinal Procedures W/O CC/MCC $18, $10,474 This code is not considered a significant procedure for the purpose of DRG assignment. A non surgical (i.e., medical) DRG is assigned to the stay according to the principal diagnosis. Lead only removal (03.94) 028 Spinal Procedures W MCC $31, Spinal Procedures W CC or Spinal Neuros mulators $18,543 Other Revision 4,8 Surgical lead revision within spinal canal (03.99) Subcutaneous revision to lead, generator (pocket), or extension (86.09) 030 Spinal Procedures W/O CC/MCC $10, Spinal Procedures W MCC $31, Spinal Procedures W CC or Spinal Neuros mulators 030 Spinal Procedures W/O CC/MCC $18, $10,474 This code is not considered a significant procedure for the purpose of DRG assignment. A non surgical (i.e., medical) DRG is assigned to the stay according to the principal diagnosis. Commonly Billed Codes 13

14 Hospital Inpa ent Coding and Payment con nued 1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpa ent Prospec ve Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospec ve Payment System and Fiscal Year 2015 Rates, Final Rule 79 Fed. Reg h p:// /pdf/ pdf. Published August 22, Accessed September 29, W MCC in MS DRG tles refers to secondary diagnosis codes that are designated as major complica ons or comorbidi es. MS DRGs W MCC have at least one major secondary complica on or comorbidity. Similarly, W CC in MS DRG tles refers to secondary diagnosis codes designated as other (non major) complica ons or comorbidi es, and MS DRGs W CC have at least one other (non major) secondary complica on or comorbidity. MS DRGs W/O CC/MCCs have no secondary diagnoses that are designated as complica ons or comorbidi es, major or otherwise. Note that some secondary diagnoses are only designated as CCs or MCCs when the condi ons were present on admission, and do not count as CCs or MCCs when the condi ons were acquired in the hospital during the stay. 3. Payment is based on the average standardized opera ng amount ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpa ent Prospec ve Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospec ve Payment System Changes and FY2015 Rates; Correc on, 79 Fed. Reg Tables 1A 1D. h p:// /pdf/ pdf. Published October 3, Accessed November 11, The payment rate shown is the standardized amounts for facili es with a wage index greater than one. The average standard amounts shown also assume facili es receive the full quality update. The payment will also be adjusted by the Wage Index for specific geographic locality. Therefore, payment for a specific hospital will vary from the stated Medicare na onal average payment levels shown. Also note that any applicable coinsurance, deduc ble, and other amounts that are pa ent obliga ons are included in the na onal average payment amount shown. 4. There are three MS DRGs for spinal procedures with a nervous system principal diagnosis (DRGs 028, 029, and 030); the difference is whether secondary diagnoses are designated as MCCs or CCs. However, for a whole system neuros mulator implanta on in which both the leads and the generator are coded, MS DRG 030 cannot be assigned. Instead, MS DRG 029 is automa cally assigned for a whole system implanta on regardless of whether a CC is present or not. If an MCC is also present with a whole system implanta on, MS DRG 028 is assigned. For other spinal procedures, such as lead only implanta on or lead removal 03.94, the full range of MS DRGs 028, 029, and 030 is available. 5. There are three MS DRGs for back and neck procedures with a musculoskeletal system principal diagnosis (DRGs 518, 519 and 520); the difference is whether secondary diagnoses are designated as MCCs or CCs. However, for a whole system neuros mulator implanta on in which both the leads and the generator are coded, MS DRG 518 is automa cally assigned regardless of whether an MCC is present. For other spinal procedures, such as lead only implanta on 03.93, the full range of MS DRGs 518, 519 and 520 is available. 6. The ICD 9 CM codes for generator implanta on are not specific to spinal neuros mula on so the MS DRGs for Other Nervous System Procedures are assigned. 7. The generator implanta on codes are designated as nervous system procedures only. When a musculoskeletal disorder is used as the principle diagnosis, the mismatch DRGs of 981, 982, and 983 are assigned. The DRGs are valid and payable. 8. Device removal without replacement and other revisions are typically performed as an outpa ent. They are shown here for the occasional scenario where removal or revision take place due to a complica on that requires inpa ent admission. For coding purposes, a neuros mulator is classified as a nervous system device. When removed or revised for complica ons or because it is no longer needed, the principal diagnosis is either various nervous system complica on codes or code V This results in assignment to Nervous System MS DRGs as shown. Commonly Billed Codes 14

15 ASC Coding and Payment Effec ve January 1, 2015 December 31, 2015 CPT Procedure Codes ASCs use CPT codes for their services. Medicare payment for procedures performed in an ambulatory surgery center is based on Medicare s ambulatory pa ent classifica on (APC) methodology for hospital outpa ent payment. However, Comprehensive APCs are used only for hospital outpa ent services and are not applied to procedures performed in ASCs. Each CPT code designated as a covered procedure in an ASC is assigned a comparable rela ve weight as under the hospital outpa ent APC system. This is then converted to a flat payment amount using a conversion factor unique to ASCs. Mul ple procedures can be paid for each claim. Certain ancillary services, such as imaging, are also covered when they are integral to covered surgical procedures, although they may not be separately payable. In general, there is no separate payment for devices; their payment is packaged into the payment for the procedure. Procedure CPT Code and Descrip on 1 Payment Indicator 2,3,4 Mul ple Procedure Discoun ng 5 Rela ve Weight 2,4 Medicare Na onal Average 2,4,6 Screening Test 7 Lead Implanta on 7 Generator Implanta on or Replacement 9 Removal of , 11,12 Leads Revision or Replacement of Leads 11,12 Revision or Removal Of Generator Percutaneous implanta on of J8 N $3,837 neuros mulator electrode array, epidural Laminectomy for implanta on of neuros mulator electrodes, plate/paddle, epidural J8 N $15, Percutaneous implanta on of J8 N $3,837 neuros mulator electrode array, epidural Laminectomy for implanta on of neuros mulator electrodes, plate/paddle, epidural Inser on or replacement of spinal neuros mulator pulse generator or receiver, direct or induc ve coupling Removal of spinal neuros mulator electrode percutaneous array(s), including fluoroscopy when performed Removal of spinal neuros mulator electrode plate/paddle placed via laminotomy or laminectomy, including fluoroscopy when performed Revision including replacement, when performed, of spinal neuros mulator electrode percutaneous array(s), including fluoroscopy when performed Revision including replacement, when performed, of spinal neuros mulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy when performed Revision or removal of implanted spinal neuros mulator pulse generator or receiver J8 N $15,854 J8 N $20,807 G2 N $759 G2 N $1,167 J8 N $3,837 J8 N $3,837 A2 N $1,167 Commonly Billed Codes 15