ABBOTT CODING GUIDE CHRONIC PAIN. Effective January 1, 2019 INTRO SPINAL CORD STIMULATION (SCS) RADIOFREQUENCY ABLATION (RFA)

Transcription

1 ABBOTT CODING GUIDE CHRONIC PAIN Effective January 1, 2019

2 CHRONIC PAIN Effective January 1, 2019 Introduction The Chronic Pain Coding Guide is intended to provide reference material related to general guidelines for the reimbursement when used consistently with the product s labeling. This guide includes information regarding coverage, coding and reimbursement. Reimbursement Hotline In addition, Abbott offers a reimbursement hotline, which provides live coding and reimbursement information from dedicated reimbursement specialists. Coding and reimbursement support is available from 8 a.m. to 5 p.m. Central Time, Monday through Friday at (855) or hce@abbott.com. This guide and all supporting documents are available Coding and reimbursement assistance is provided subject to the disclaimers set forth in this guide. Disclaimer This document and the information contained herein is for general information purposes only and is not intended and does not constitute legal, reimbursement, coding, business or other advice. Furthermore, it is not intended to increase or maximize payment by any payer. Nothing in this document should be construed as a guarantee by Abbott regarding levels of reimbursement, payment or charge, or that reimbursement or other payment will be received. Similarly, nothing in this document should be viewed as instructions for selecting any particular code. The ultimate responsibility for coding and obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and veracity of all coding and claims submitted to third-party payers. Also note that the information presented herein represents only one of many potential scenarios, based on the assumptions, variables and data presented. In addition, the customer should note that laws, regulations, coverage and coding policies are complex and updated frequently. Therefore, the customer should check with their local carriers or intermediaries often and should consult with legal counsel or a financial, coding or reimbursement specialist for any coding, reimbursement or billing questions or related issues. This information is for reference purposes only. It is not provided or authorized for marketing use.

3 ABBOTT CODING GUIDE SPINAL CORD STIMULATION (SCS) Effective January 1, 2019

4 PAGE 1 PAGE 2 PAGE 3 Physician 1 CPT CODE WORK RVU NATIONAL MEDICARE RATE FACILITY NON FACILITY TRIAL PROCEDURE Percutaneous implantation of neurostimulator electrode array, epidural 7.15 $426 $1,657 PERMANENT PROCEDURES Percutaneous implantation of neurostimulator electrode array, epidural 7.15 $426 $1, Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling (Do not report 63685) in conjunction with for the same pulse generator or receiver) REVISION AND REMOVAL PROCEDURES Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy when performed Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed $869 NA 5.19 $375 NA 5.08 $336 $ $879 NA 7.75 $467 $845 It is incumbent upon the physician to determine which, if any modifiers should be used first.

5 PAGE 1 PAGE 2 PAGE 3 Physician 1 CPT CODE REVISIONS AND REMOVAL PROCEDURES (CONTINUED) Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) via laminotomy or laminectomy, including fluoroscopy, when performed WORK RVU NATIONAL MEDICARE RATE FACILITY NON FACILITY $911 NA Revision or removal of implanted spinal neurostimulator pulse generator or receiver 5.30 $387 NA ELECTRONIC ANALYSIS AND DEVICE PROGRAMMING 95970* Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter,without programming 0.35 $19 $19 * A physician or an auxiliary person employed by and under the direct supervision of that physician may provide, with or without the support of the manufacturer's representative, analysis and programming of a patient's medical product or device "incident to" the physician's other services performed in the office setting. A patient or his payer should not be billed for analysis and programming services performed at the direction of the physician by a manufacturer's representative. Contact your MAC or other payer for any questions regarding coverage, coding and payment. It is incumbent upon the physician to determine which, if any modifiers should be used first.

6 PAGE 1 PAGE 2 PAGE 3 Physician 1 CPT CODE ELECTRONIC ANALYSIS AND DEVICE PROGRAMMING (CONTINUED) 95971* 95972* Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional WORK RVU NATIONAL MEDICARE RATE FACILITY NON FACILITY 0.78 $42 $ $43 $58 * A physician or an auxiliary person employed by and under the direct supervision of that physician may provide, with or without the support of the manufacturer's representative, analysis and programming of a patient's medical product or device "incident to" the physician's other services performed in the office setting. A patient or his payer should not be billed for analysis and programming services performed at the direction of the physician by a manufacturer's representative. Contact your MAC or other payer for any questions regarding coverage, coding and payment. It is incumbent upon the physician to determine which, if any modifiers should be used first.

7 PAGE 1 PAGE 2 PAGE 3 Hospital Outpatient 2 CPT CODE STATUS INDICATOR APC NATIONAL MEDICARE RATE TRIAL PROCEDURE Percutaneous implantation of neurostimulator electrode array, epidural J $5,980 PERMANENT PROCEDURES Percutaneous implantation of neurostimulator electrode array, epidural J $5, Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural J $18, Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling J $27,698 J1 = Hospital Part B services paid through a comprehensive APC

8 PAGE 1 PAGE 2 PAGE 3 Hospital Outpatient 2 CPT CODE STATUS INDICATOR APC NATIONAL MEDICARE RATE IMPLANTABLE PULSE GENERATOR (IPG) AND PROGRAMMINGª 95970* 95971* 95972* Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/ transmitter,without programming Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s],interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/ transmitter,without programming Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/ transmitter programming by physician or other qualified health care professional Q $106 S 5742 $118 S 5742 $118 Q1 = Packaged APC payment if billed on same date of service as HCPCS assigned status indicator S, T, V or X S = Procedure or service, not discounted when multiple * A physician or an auxiliary person employed by and under the direct supervision of that physician may provide, with or without the support of the manufacturer's representative, analysis and programming of a patient's medical product or device "incident to" the physician's other services performed in the office setting. A patient or his payer should not be billed for analysis and programming services performed at the direction of the physician by a manufacturer's representative. Contact your MAC or other payer for any questions regarding coverage, coding and payment. a Parameters include: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature (e.g., rigidity, dyskinesia, tremor).

9 PAGE 1 PAGE 2 PAGE 3 Hospital Outpatient 2 CPT CODE STATUS INDICATOR APC NATIONAL MEDICARE RATE REVISION AND REMOVAL PROCEDURES Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Q $1,632 Q $2,880 J $5,980 J $18, Revision or removal of implanted spinal neurostimulator pulse generator or receiver Q $2,880 J1 = Hospital Part B services paid through a comprehensive APC Q2 = T-packaged codes

10 PAGE 1 PAGE 2 Ambulatory Surgery Center 4 (ASC) CPT CODE PAYMENT INDICATOR MULTI-PROCEDURE DISCOUNT NATIONAL MEDICARE RATE TRIAL PROCEDURE Percutaneous implantation of neurostimulator electrode array, epidural PERMANENT PROCEDURES Percutaneous implantation of neurostimulator electrode array, epidural Laminectomy implant of neurostimulator electrodes, plate/ paddle, epidural Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling (Do not report in conjunction with for the same pulse generator or receiver) J8 N $4,449 J8 N $4,449 J8 N $15,741 J8 N $22,580 J8 = Device-intensive procedure; paid at adjusted rate.

11 PAGE 1 PAGE 2 Ambulatory Surgery Center 4 (ASC) CPT CODE PAYMENT INDICATOR MULTI-PROCEDURE RATE NATIONAL MEDICARE RATE REVISION AND REMOVAL PROCEDURES Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Revision or removal of implanted spinal neurostimulator pulse generator or receiver G2 N $781 G2 N $1,483 J8 N $4,091 J8 N $14,142 A2 N $1,483 A2 = Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. G2 = Non office-based surgical procedure added in CY2008 or later; payment base on OPPS relative payment rate. J8 = Device-intensive procedure; paid at adjusted rate.

12 PAGE 1 PAGE 2 PAGE 3 PAGE 4 Hospital Inpatient 3 PROCEDURE LEAD INSERTION LEAD REMOVAL LEAD REVISION POSSIBLE ICD-10 PCS CODE 00HU0MZ 00HU3MZ 00HV0MZ 00HV3MZ 00PU0MZ 00PU3MZ 00PV0MZ 00PV3MZ 00WU0MZ 00WU3MZ 00WVOMZ 00WV3MZ Insertion of neurostimulator lead into spinal canal, open approach Insertion of neurostimulator lead into spinal canal, percutaneous approach Insertion of neurostimulator lead into spinal cord, open approach Insertion of neurostimulator lead into spinal cord, percutaneous approach Removal of neurostimulator lead from spinal canal, open approach Removal of neurostimulator lead from spinal canal, percutaneous approach Removal of neurostimulator lead from spinal cord, open approach Removal of neurostimulator lead from spinal cord, percutaneous approach Revision of neurostimulator lead in spinal canal, open approach Revision of neurostimulator lead in spinal canal, percutaneous approach Revision of neurostimulator lead in spinal cord, open approach Revision of neurostimulator lead in spinal cord, percutaneous approach LEAD REPLACEMENT Two codes are required to identify a device replacement; one code for the removal of the existing device and one code for the implantation of a new device Effective Dates: October 1, September 30, 2019

13 PAGE 1 PAGE 2 PAGE 3 PAGE 4 Hospital Inpatient 3 PROCEDURE GENERATOR IMPLANT GENERATOR REMOVAL GENERATOR REVISION POSSIBLE ICD-10 PCS CODE 0JH60BZ 0JH63BZ 0JH70BZ 07H73BZ 0JH80BZ 0JH83BZ 0JPT0MZ 0JPT3MZ 0JWT0MZ 0JWT3MZ Insertion of single array stimulator generator into chest subcutaneous tissue and fascia, open approach Insertion of single array stimulator generator into chest subcutaneous tissue and fascia, percutaneous approach Insertion of single array stimulator generator into back subcutaneous tissue and fascia, open approach Insertion of single array stimulator generator into back subcutaneous tissue and fascia, percutaneous approach Insertion of single array stimulator generator into abdomen subcutaneous tissue and fascia, open approach Insertion of single array stimulator generator into abdomen subcutaneous tissue and fascia, percutaneous approach Removal of stimulator generator from trunk subcutaneous tissue and fascia, open approach Removal of stimulator generator from trunk subcutaneous tissue and fascia, percutaneous approach Revision of stimulator generator from trunk subcutaneous tissue and fascia, open approach Revision of stimulator generator from trunk subcutaneous tissue and fascia, percutaneous approach GENERATOR REPLACEMENT Two codes are required to identify a device replacement: one code for the removal of the existing device and one code for the implantation of a new device. Effective Dates: October 1, September 30, 2019

14 PAGE 1 PAGE 2 PAGE 3 PAGE 4 Hospital Inpatient 3 PROCEDURE SCENARIO TYPICAL MS-DRG ASSIGNMENT MS-DRG TITLE NATIONAL MEDICARE RATE Implant or replace SCS system; generator and lead(s) Pain disorder or due to causalgia or RSD, and other nervous system disorders Pain due to musculoskeletal disorders 028 Spinal procedures with MCC $32, Spinal procedures with CC or spinal neurostimulators Back and neck procedure except spinal fusion with MCC or disc device/neurostim $19,279 $18, Peripheral/cranial nerve and other nervous system procedure with MCC $23,999 Pain disorder or due to causalgia or RSD, and other nervous system disorders 041 Peripheral/cranial nerve and other nervous system procedure with CC or peripheral neurostim $14,409 Implant or replace generator only Peripheral/cranial nerve and other nervous system procedure without CC/ MCC Extensive O.R. procedure unrelated to principal diagnosis with MCC $11,434 $26,701 Pain due to musculoskeletal disorders 982 Extensive O.R. procedure unrelated to principal diagnosis with CC $14, Extensive O.R. procedure unrelated to principal diagnosis without CC/ MCC $9,587 Effective Dates: October 1, September 30, 2019

15 PAGE 1 PAGE 2 PAGE 3 PAGE 4 Hospital Inpatient 3 PROCEDURE SCENARIO TYPICAL MS-DRG ASSIGNMENT MS-DRG TITLE NATIONAL MEDICARE RATE Implant or replace lead(s) only Pain disorder or due to causalgia or RSD, and other nervous system disorders 028 Spinal procedures with MCC $32, Spinal procedures with CC or spinal neurostimulators $19, Spinal procedures without CC/MCC $13, Back and neck procedure except spinal fusion with MCC or disc device/neurostim $18,940 Pain due to musculoskeletal disorders 519 Back and neck procedure except spinal fusion with CC $11, Back and neck procedure except spinal fusion with without CC/MCC $8, Spinal procedures with MCC $32,836 Remove SCS system; generator and lead(s) Remove or revise lead(s) only 029 Spinal procedures with CC or spinal neurostimulators $19, Spinal procedures without CC/MCC $13,292 Remove, generator only These codes are not considered "significant procedures" for the purpose of MS-DRG assignment. A non-surgical (i.e., medical) MS-DRG is assigned to the inpatient hospital admission according to the principal diagnosis. Effective Dates: October 1, September 30, 2019

16 HCPCS 1 HCPCS 2 DIAGNOSIS HCPCS Device Category C-Codes 6 C-CODE C-CODES FOR MEDICARE HOSPITAL OUTPATIENT PROCEDURES C1767 C1778 C1787 C1820 C1883 C1897 Generator Neurostimulator lead (use for permanent procedure) Patient programmer, neurostimulator Generator, neurostimulator (implantable), with rechargeable battery and charging system Adapter or extension Lead neurostimulator test kit, pacing lead (use for trial procedures)

17 HCPCS 1 HCPCS 2 DIAGNOSIS HCPCS Device Codes 6 and Descriptions C-CODE LEAD L8680 Implantable neurostimulator electrode, each IMPLANTABLE PULSE GENERATOR (IPG) L8679 L8686 L8687 L8688 Implantable neurostimulator pulse generator, any type Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension EXTERNAL RECHARGER L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only PATIENT PROGRAMMER L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

18 HCPCS 1 HCPCS 2 DIAGNOSIS ICD-10CM Diagnosis Codes 5 Diagnosis codes are used by both hospitals and physicians to document the indication for the procedure. For Spinal Cord Stimulation (SCS) patients, there are many possible diagnosis code scenarios and a wide variety of possible combinations. The possible scenarios and combinations are too numerous to capture in this document. The customer should check with their local carriers or intermediaries and should consult with legal counsel or a financial, coding or reimbursement specialist for coding, reimbursement or billing questions related to ICD-10CM diagnosis codes.

19 PHYSICIAN CODING HOSPITAL OUTPATIENT ASC ADDITIONAL CODES OTHER BILLING REQUIREMENTS ABBOTT CODING GUIDE RADIOFREQUENCY ABLATION (RFA) Effective January 1, 2019

20 PHYSICIAN CODING HOSPITAL OUTPATIENT ASC ADDITIONAL CODES OTHER BILLING REQUIREMENTS CODING AND REIMBURSEMENT FOR RADIOFREQUENCY ABLATION (RFA) Physician 1 CPT CODE CERVICAL SPINE/THORACIC SPINE Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint LUMBAR SPINE/SACRAL SPINE Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint OTHER PERIPHERAL NERVES WORK RVU NATIONAL MEDICARE RATE FACILITY NON FACILITY 3.84 $233 $ $70 $ $228 $ $62 $ Destruction by neurolytic agent; other peripheral nerve or branch 1.23 $97 $ Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) 0.54 NA $103 It is incumbent upon the physician to determine which, if any modifiers should be used first.

21 PHYSICIAN CODING HOSPITAL OUTPATIENT ASC ADDITIONAL CODES OTHER BILLING REQUIREMENTS CODING AND REIMBURSEMENT FOR RADIOFREQUENCY ABLATION (RFA) Hospital Outpatient 2 CPT CODE 2 STATUS INDICATOR APC NATIONAL MEDICARE RATE CERVICAL SPINE/THORACIC SPINE Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint LUMBAR SPINE/SACRAL SPINE Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint OTHER PERIPHERAL NERVES J $1,631 N NA Packaged J $1,631 N NA Packaged Destruction by neurolytic agent; other peripheral nerve or branch T 5443 $ Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) N NA Packaged J1 = Hospital Part B services paid through a comprehensive APC N = Items and services packaged into APC rates T = Significant procedure, multiple reduction applies

22 PHYSICIAN CODING HOSPITAL OUTPATIENT ASC ADDITIONAL CODES OTHER BILLING REQUIREMENTS CODING AND REIMBURSEMENT FOR RADIOFREQUENCY ABLATION (RFA) Ambulatory Surgery Center 4 (ASC) CPT CODE PAYMENT INDICATOR MULTI-PROCEDURE DISCOUNT NATIONAL MEDICARE RATE CERVICAL SPINE/THORACIC SPINE Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint LUMBAR SPINE/SACRAL SPINE Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint OTHER PERIPHERAL NERVES G2 Y $781 N1 N NA G2 Y $781 N1 N NA Destruction by neurolytic agent; other peripheral nerve or branch P3 Y $ Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) N1 NA NA G2 = Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment rate. N1 = Package service/item; no separate payment made. P3 = Office-based surgical procedure added to ASC list in CY2008 or later with MPFS non-facility PE RVUs payment based on non-facility PE RVUs.

23 PHYSICIAN CODING HOSPITAL OUTPATIENT ASC ADDITIONAL CODES OTHER BILLING REQUIREMENTS CODING AND REIMBURSEMENT FOR RADIOFREQUENCY ABLATION (RFA) ICD-10CM Diagnosis Codes 5 Diagnosis codes are used by both hospitals and physicians to document the indication for the procedure. For Radiofrequency Ablation (RFA) patients, there are many possible diagnosis code scenarios and a wide variety of possible combinations. The possible scenarios and combinations are too numerous to capture in this document. The customer should check with their local carriers or intermediaries and should consult with legal counsel or a financial, coding or reimbursement specialist for coding, reimbursement or billing questions related to ICD-10CM diagnosis codes.

24 PHYSICIAN CODING HOSPITAL OUTPATIENT ASC ADDITIONAL CODES OTHER BILLING REQUIREMENTS CODING AND REIMBURSEMENT FOR RADIOFREQUENCY ABLATION (RFA) Other Billing Requirements Pre-Procedure Requirements Most insurance providers require at least one diagnostic procedure for each treated site, with some requiring two. Please check with the payer before performing any radiofrequency (RF) procedure to be sure you have completed all required step therapies. Appeals There are numerous reasons that a facility or physician may face a denied, pended or underpaid claim. Claims are typically denied or pended for four reasons: The claims processors have made an administrative error The claim forms contain clerical errors The payer has not deemed the procedure to be medically necessary The payer s requests for information have gone unanswered by the patient Appealing Denied Claims A denied claim can be appealed. When a claim has been denied, review the Explanation of Benefits (EOB) for an explanation of the denial. Immediately contact the payer if the EOB does not explain the reason for the denial and request an explanation. In cases where the denial was a result of a clerical error on the claim form, confirm the correct code with the payer and resubmit the corrected claim form. Other reasons for a denied claim may include: The technology is considered investigational The CPT code does not meet the diagnosis code The medical necessity has not been determined Should your claim have been denied for one of these reasons, it is best to contact the payer directly in order to offer additional information about the procedure. You should ask the claims processor to indicate which additional materials should be provided in order to potentially reverse the original coverage determination. If you feel that your claim has been underpaid, contact the claims office indicated on the patient s EOB and request a review of your claim. Reasons for underpayment of a procedure include but are not limited to: The coding of the procedure performed is incorrect The lack or misuse of an appropriate modifier The lack of supporting documentation You will find that each payer has its own unique review process. It is best to contact the payer for the exact guidelines. In most cases, however, you will be asked to submit your appeal request in writing. When contacting the payer, be sure to inquire as to where the request should be sent and to whose attention it should be directed. If you have additional reimbursement questions, please call the Reimbursement Hotline at (855)

25 References 1. Physician Prospective Payment-Final rule with Comment Period and Final CY2019 Payment Rates. CMS-1693-F: Federal-Regulation-Notices-Items/CMS-1693-F.html 2. Hospital Outpatient Prospective Payment-Final Rule with Comment Period and Final CY2019 Payment Rates. CMS-1695-FC: HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html 3. Hospital Inpatient Prospective Payment-Final Rule with Comment Period and Final FY2019 Payment Rates. CMS-1694-F: AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page-Items/FY2019-IPPS-Final-Rule-Regulations.html 4. Ambulatory Surgical Center Payment-Final Rule CY2019 Payment Rates. CMS-1695-FC: Regulations-and-Notices-Items/CMS-1695-FC.html 5. American Medical Association 2019 ICD-10-CM: The Complete Official Codebook. Edition 1; CMS, 2019 Alpha-Numeric Index HCPS code set: html?dlpage=1&dlentries=10&dlsort=0&dlsortdir=descending Abbott One St. Jude Medical Dr., St. Paul, MN 55117, USA, Tel: Indicates a trademark of the Abbott group of companies. Indicates a third party trademark, which is property of its respective owner Abbott. All Rights Reserved. SJM-HER (7) Item approved for U.S. use only.