Reimbursement Guidelines for Pain Management Procedures 1

GE Healthcare Reimbursement Guidelines for Pain Management Procedures 1 April 2015 www.gehealthcare.com/reimbursement

This overview addresses coding, coverage, and payment for pain management procedures when performed in the hospital outpatient, inpatient department, as well as the physician s office. While this advisory focuses on Medicare program policies, these policies may also be applicable to selected private payers throughout the country. The following provides 2015 national Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Ambulatory Payment Category (APC) payment rates. Payment will vary in geographic locality. 2015 National Average MPFS and APC Reimbursement for Pain Management Procedures Injection Spine CPT 2 /HCPCS Code 62280 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid 62281 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic Physician Reimbursement Component Medicare Physician Fee Schedule Amount 3 * $163.86 ** $306.87 $158.83 $239.32 APC Hospital Outpatient Payment 4 0203 $1470.03 62282 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal) $151.64 $301.48 0203 $1470.03 62284 Injection procedure for myelography and/or computed tomography, lumbar $89.83 $187.21 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar $592.90 0221 $2947.54 62290 Injection procedure for discography, each level $178.59 $342.09 62291 Injection procedure for discography, each level; cervical or thoracic $178.23 $345.32

62292 Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels $603.32 0203 No Separate Payment 62294 Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal $820.36 0207 No Separate Payment 62302 Myelography via lumbar injection, including radiological supervision and interpretation; cervical $129.72 $249.74 0274 No Separate Payment 62303 Myelography via lumbar injection, including radiological supervision and interpretation; thoracic $131.52 $259.44 0274 No Separate Payment 62304 Myelography via lumbar injection, including radiological supervision and interpretation $127.56 $246.50 0274 No Separate Payment 62305 Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (eg, lumbar/ thoracic, cervical/ thoracic, lumbar/cervical, lumbar/thoracic/ cervical) $133.67 $269.14 0274 $826.95 62310 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic $112.47 $245.43 0207 No Separate Payment 62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) $92.71 $226.02

62318 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic 62319 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) $102.77 $234.29 $99.18 $171.40 Catheter Implantation 62270 Spinal puncture, lumbar, diagnostic $81.57 $163.86 62272 Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter) $87.68 $206.62 62273 Injection, epidural, of blood or clot patch $117.86 $177.51 62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/ infusion pump; without laminectomy $417.19 0224 $3662.54 62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/ infusion pump; with laminectomy $904.09 0208 $4113.17

62355 Removal of previously implanted intrathecal or epidural Reservoir/Pump Implantation 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump 95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed 95991 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care professional Reservoir/Pump Implantation 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir $281.36 $316.93 $453.12 $91.27 $40.25 $122.53 $315.36 0203 $1470.03 0224 $3662.54 0227 $15,572.43 0439 $173.59 0439 $173.59 0224 $3662.54 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump $450.87 0227 $15,572.43 95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed 95991 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care professional $90.82 $40.05 $121.92 0439 $173.59 0439 $173.59

Intrathecal or Epidural Drug Infusion Pump Implantation 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming $403.17 0227 $15,572.43 62365 Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion $310.82 0221 $2947.54 62367 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill $25.87 $41.68 0691 $247.54 62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming $36.29 $57.85 0691 $247.54 62369 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill $36.65 $123.25 0691 $247.54 62370 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill (requiring skill of a physician or other qualified health care professional) Neurostimulators (Spinal) $48.51 $130.08 0691 $247.54 63650 Percutaneous implantation of neurostimulator electrode array, epidural $427.25 $1356.49 0061 $5290.65

63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural $869.23 0039 $17,106.04 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed $333.46 $593.98 0229 $1,384.07 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed $880.73 0688 $2,128.81 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed $468.21 $807.43 0061 $5,290.65 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed $900.85 0061 $5,290.65 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling $382.33 0318 $26,162.39 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver $385.93 0688 $2,128.81

Introduction/Injection of anesthetic Agent (Nerve Block), Diagnostic or Therapeutic Somatic Nerves 64400 Injection, anesthetic agent; trigeminal nerve, any division or branch 64402 Injection, anesthetic agent; facial nerve $73.30 $130.44 $80.85 $133.31 0420 $131.75 64405 Injection, anesthetic agent; greater occipital nerve 64408 Injection, anesthetic agent; vagus nerve 64410 Injection, anesthetic agent; phrenic nerve 64412 Injection, anesthetic agent; spinal accessory nerve 64413 Injection, anesthetic agent; cervical plexus 64415 Injection, anesthetic agent; brachial plexus, single 64416 Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement) 64417 Injection, anesthetic agent; axillary nerve 64418 Injection, anesthetic agent; suprascapular nerve 64420 Injection, anesthetic agent; intercostal nerve, single 64421 Injection, anesthetic agent; intercostal nerves, multiple, regional block $65.40 $103.49 $88.76 $119.30 $70.79 $122.89 $74.38 $145.53 $85.16 $132.24 $66.84 $120.02 $81.57 $72.59 $131.88 $79.41 $149.84 $70.07 $114.99 $94.51 $153.08

64425 Injection, anesthetic agent; ilioinguinal, iliohypogastric 64430 Injection, anesthetic agent; pudendal nerve 64435 Injection, anesthetic agent; paracervical (uterine) nerve 64445 Injection, anesthetic agent; sciatic nerve, single 64446 Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement) $95.94 $134.39 $85.88 $143.02 $86.24 $138.34 $74.38 $137.98 $81.93 64447 Injection, anesthetic agent; femoral nerve, single 64448 Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement) 64449 Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) 64450 Injection, anesthetic agent; other peripheral nerve or branch 64455 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton s neuroma) 64479 Injection(s), anesthetic agent and/ or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level $67.91 $121.81 $72.94 $86.24 $47.07 $81.93 $35.57 $48.51 $137.27 $240.75 0203 $1470.03 +64480 Injection(s), anesthetic agent and/ or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) $65.40 $115.35

64483 Injection(s), anesthetic agent and/ or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level $116.78 $223.51 0207 +64484 Injection(s), anesthetic agent and/ or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) $53.54 $89.12 64486 (New code as of 2015) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed) $65.04 $126.85 64487 (New code as of 2015) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by continuous infusion(s) (includes imaging guidance, when performed $74.74 $154.87 64488 (New code as of 2015) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed) $81.57 $155.95 64489 (New code as of 2015) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by continuous infusions (includes imaging guidance, when performed $91.63 $216.68 Paravertebral Spinal Nerves and Branches 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level $110.68 $194.40 0207

+64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) $62.52 $96.30 +64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) $63.24 $96.66 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level $94.51 $176.07 +64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) $53.90 $88.76 +64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) $54.62 $89.12 Autonomic Nerves 64505 Injection, anesthetic agent; sphenopalatine ganglion 64508 Injection, anesthetic agent; carotid sinus (separate procedure) 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) $89.47 $107.08 $75.82 $64.68 $76.18 $130.08

64517 Injection, anesthetic agent; superior hypogastric plexus 64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) 64530 Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring Destruction by Neurolytic Agent 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint $126.49 $184.70 $83.72 $189.73 $95.58 $194.76 $234.65 $425.81 0203 $1,470.03 +64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) $70.43 $190.09 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint $231.77 $422.22 0203 $1,470.03 +64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) $62.16 $173.92 Musculoskeletal Injections 20552 Injection(s); single or multiple trigger point(s),1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s) $38.81 $56.06 $44.20 $65.04

20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) 20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting 20605 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance 20606 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting $36.65 $48.51 $47.43 $73.66 $38.09 $50.67 $54.26 $81.57 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance $47.43 $61.45 20611 Arthrocentesis, aspiration and/ or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting $63.96 $94.15 64999 Unlisted procedure, nervous system Ultrasound-related Category III Codes 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level

+0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) +0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level +0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) +0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) 0228T Injection(s), anesthetic agent and/ or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level +0229T Injection(s), anesthetic agent and/ or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure)

0230T Injection(s), anesthetic agent and/ or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single +0231T Injection(s), anesthetic agent and/ or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure) Vertebroplasty 22510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic $471.45 $1800.63 0050 $2602.13 22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral $442.70 $1784.10 0050 $2602.13 22512 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) $219.91 $1001.47 Kyphoplasty 22510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic $471.45 $1800.63 0050 $2602.13 22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral $442.70 $1784.10 0050 $2602.13

22512 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) $219.91 $4524.02 Fluoroscopic Guidance 77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) Professional*** $28.39 Technical**** $64.68 Global $93.07 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) Professional $30.90 Technical $55.34 Global $86.24 Ultrasound Guidance 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Professional $33.78 Technical $27.31 Global $61.09 * is the payment made to the physician when the procedure is performed in a hospital or ASC. ** Non- is the payment to the physician when the procedure is performed in the physician s office. *** Professional (-26) - The professional component is the interpretation of the results of the test. When the professional component is reported separately the service may be identified by adding modifier 26. ****Technical (-TC) - The technical component is the equipment and technician performing the test. This is identified by adding modifier TC to the procedure code identified for the technical component charge. + indicates add-on code Modifiers Modifiers explain that a procedure or service was changed without changing the definition of the CPT code set. Here are some common modifiers related to the use of pain management procedures. This is not an all-inclusive list of applicable modifiers. Refer to your current CPT and/or HCPCS manual for a complete list of modifiers and instructions for specific CPT codes. -22- Increased Procedural s This modifier would be appended to the appropriate CPT code when the work required to provide a service is substantially greater than typically required. Documentation must support the additional work and the reason for it.

-50 - Bilateral Procedures Bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5-digit code. Do not append this modifier if bilateral service is identified in the listings/description of the CPT code itself. -51 Multiple Procedures Bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5-digit code. Do not append this modifier if bilateral service is identified in the listings/description of the CPT code itself. -52 Reduced s When a service or procedure is partially reduced or eliminated at the physician s discretion, modifier 52 would be appended to the applicable procedure code. -53 Discontinued Procedure The physician may choose to terminate a surgical or diagnostic procedure in certain circumstances. If the procedure was started and then discontinued, the modifier 53 would be appended to the procedure code. -59 Distinct Procedural This modifier is used when it is necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. This modifier may be used with procedure codes that aren t usually billed together, but may be due to certain circumstances. -76 Repeat Procedure or by Same Physician This modifier would be used when it a procedure or service was repeated subsequent to the original procedure or service. -77 Repeat Procedure by Another Physician This modifier is used to indicate that a procedure or service performed by another physician was repeated. -78 Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period When another unplanned procedure was performed during the postoperative period of the initial procedure, this modifier would be appended to the procedure code. Hospital Inpatient - ICD-9-CM Procedure Coding ICD-9-CM procedure codes are used to report procedures performed in a hospital inpatient setting. The following are ICD-9-CM procedure codes that are commonly used to report pain management procedures in the inpatient setting (not all inclusive): ICD-9-CM Description 03.8 Injection of destructive agent into spinal canal 03.90 Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances 03.91 Injection of anesthetic into spinal canal for analgesia 03.92 Injection of other agent into spinal canal 03.93 Implantation or replacement of spinal neurostimulator lead(s) 03.94 Removal of spinal neurostimulator lead(s) 03.96 Percutaneous denervation of facet 03.99 Other operations on spinal cord and spinal canal structures 04.81 Injection of anesthetic into peripheral nerve for analgesia

05.31 Injection of anesthetic into sympathetic nerve for analgesia 76.96 Injection of therapeutic substance into temporomandibular joint 81.91 Arthrocentesis 81.92 Injection of therapeutic substance into joint or ligament 82.92 Aspiration of bursa of hand 82.94 Injection of therapeutic substance into bursa of hand 82.95 Injection of therapeutic substance into tendon of hand 82.96 Other injection of locally-acting therapeutic substance into soft tissue of hand 83.94 Aspiration of bursa 83.96 Injection of therapeutic substance into bursa 83.98 Injection of locally acting therapeutic substance into other soft tissue 86.05 Incision with removal of foreign body or device from skin and subcutaneous tissue 86.06 Insertion of totally implantable infusion pump 86.09 Other incision of skin and subcutaneous tissue 86.94 Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable 86.95 Insertion or replacement of multiple array neurostimulator pulse generator, not specified as rechargeable 86.96 Insertion or replacement of other neurostimulator pulse generator 87.21 Contrast myelogram 87.22 Other x-ray of cervical spine 87.23 Other x-ray of thoracic spine 87.24 Other x-ray of lumbosacral spine 87.29 Other x-ray of spine 88.38 Other computerized axial tomography 88.39 X-ray, other and unspecified 88.79 Other diagnostic ultrasound 89.39 Other nonoperative measurements and examinations 99.23 Injection of steroid 99.29 Injection or infusion of other therapeutic or prophylactic substance ICD-9-CM Diagnosis Coding Because of the vast array of diagnoses related to the aforementioned procedures, please check with your payer regarding appropriate ICD-9-CM diagnosis code selection. MS-DRG Medicare Reimbursement The following table lists some of the common Medicare MS-DRGs associated with pain management procedures and their 2015 National Average reimbursement rates. Please note that the final MS-DRG assignment will be based on the combination of ICD-9-CM diagnosis and procedure codes as well as the presence, or lack of, complications and/or comorbidities. Only one MS-DRG is assigned to a patient for a particular hospital admission. MS-DRG Description 2015 Medicare Rate 023 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis with MCC or Chemo Implant 024 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without MCC $31,090.37 $22,000.28 029 Spinal Procedures with CC or Spinal Neurostimulator $18,542.53 040 Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC $22,293.07

041 Peripheral/Cranial Nerve and Other Nervous System Procedures with CC or Peripheral Neurostimulator 042 Peripheral/Cranial Nerve and Other Nervous System Procedures without CC/ MCC 518 Back and Neck Procedures Except Spinal Fusion with MCC or Disc Device/ Neurostimulator $12,490.00 $10,915.32 $17,987.55 579 579 Other Skin, Subcutaneous Tissue and Breast Procedures with MCC $16,011.09 580 Other Skin, Subcutaneous Tissue and Breast Procedures with CC $9,236.25 581 Other Skin, Subcutaneous Tissue and Breast Procedures without CC/MCC $6,658.76 Documentation Requirements As with all medical procedures performed, the following requirements should be met in order to be considered for coverage and reimbursement by Medicare: Medical necessity as determined by the payer Completeness Documented in the patient s medical record Coverage Policies Medicare carriers may issue local coverage decisions (LCDs) addressing the requirements that must be met for services to be covered. It is strongly recommended that physicians review these LCDs or contact their local payers to inquire about these requirements. Medicare LCDs may be found at this link: http://www.cms.gov/medicarecoverage-database/ Coverage by private payers varies by payer and by plan. It is important that you contact the payer prior to submitting claims to determine their requirements. DISCLAIMER THE INFORMATION PROVIDED WITH THIS NOTICE IS GENERAL REIMBURSEMENT INFORMATION ONLY; IT IS NOT LEGAL ADVICE, NOR IS IT ADVICE ABOUT HOW TO CODE, COMPLETE OR SUBMIT ANY PARTICULAR CLAIM FOR PAYMENT. IT IS ALWAYS THE PROVIDER S RESPONSIBILITY TO DETERMINE AND SUBMIT APPROPRIATE CODES, CHARGES, MODIFIERS AND BILLS FOR THE SERVICES THAT WERE RENDERED. THIS INFORMATION IS PROVIDED AS OF JANUARY 1, 2015 AND ALL CODING AND REIMBURSEMENT INFORMATION IS SUBJECT TO CHANGE WITHOUT NOTICE. PAYERS OR THEIR LOCAL BRANCHES MAY HAVE DISTINCT CODING AND REIMBURSEMENT REQUIREMENTS AND POLICIES. BEFORE FILING ANY CLAIMS, PROVIDERS SHOULD VERIFY CURRENT REQUIREMENTS AND POLICIES WITH THE LOCAL PAYER. THIRD PARTY REIMBURSEMENT AMOUNTS AND COVERAGE POLICIES FOR SPECIFIC PROCEDURES WILL VARY INCLUDING BY PAYER, TIME PERIOD AND LOCALITY, AS WELL AS BY TYPE OF PROVIDER ENTITY. THIS DOCUMENT IS NOT INTENDED TO INTERFERE WITH A HEALTH CARE PROFESSIONAL S INDEPENDENT CLINICAL DECISION MAKING. OTHER IMPORTANT CONSIDERATIONS SHOULD BE TAKEN INTO ACCOUNT WHEN MAKING DECISIONS, INCLUDING CLINICAL VALUE. THE HEALTH CARE PROVIDER HAS THE RESPONSIBILITY, WHEN BILLING TO GOVERNMENT AND OTHER PAYERS (INCLUDING PATIENTS), TO SUBMIT CLAIMS OR INVOICES FOR PAYMENT ONLY FOR PROCEDURES WHICH ARE APPROPRIATE AND MEDICALLY NECESSARY. YOU SHOULD CONSULT WITH YOUR REIMBURSEMENT MANAGER OR HEALTHCARE CONSULTANT, AS WELL AS EXPERIENCED LEGAL COUNSEL.

2015 General Electric Company All rights reserved. General Electric Company reserves the right to make changes in specifications and features shown herein, or discontinue the product described at any time without notice or obligation. Contact your GE Representative for the most current information. *GE, GE Monogram and OEC are trademarks of General Electric Company. GE OEC Medical Systems, Inc. Healthcare Re-imagined GE Healthcare, Surgery Americas: Phone 801-328-9300 Fax 801-328-4300 GE is dedicated to helping you transform healthcare delivery by driving critical breakthroughs in biology and technology. Our expertise in medical imaging and information technologies, medical diagnostics, patient monitoring systems, drug discovery, and biopharmaceutical manufacturing technologies is enabling healthcare professionals around the world discover new ways to predict, diagnose and treat disease earlier. We call this model of care Early Health. The goal: to help clinicians detect disease earlier, access more information and intervene earlier with more targeted treatments, so they can help their patients live their lives to the fullest. Re-think, Re-discover, Re-invent, Re-imagine. 1. Information presented in this document is current as of January 1, 2015. Any subsequent changes which may occur in coding, coverage and payment are not reflected herein. 2. Current Procedural Terminology (CPT) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. 3. Third party reimbursement amounts and coverage policies for specific procedures will vary by payer and by locality. The MPFS payment is based on relative value units published in Federal Register/Vol. 79, No. 219 /Thursday, November 13, 2014 as well as subsequent updates and legislation. Amounts do not necessarily reflect any subsequent changes in payment since publication. The fee schedule amounts indicated are effective for services provided from 7/1/15 through 12/31/15 only. To confirm reimbursement rates for specific codes, consult with your local Medicare contractor 4. Third party reimbursement amounts and coverage policies for specific procedures will vary by payer and by locality. The technical component is a payment amount assigned to an Ambulatory Payment Classification under the hospital outpatient prospective payment system, as published in Federal Register/Vol. 79, No. 217 / November 10 2014. The professional component is generally paid based on the Medicare physician fee schedule. Amounts do not necessarily reflect any subsequent changes in payment since publication. To confirm reimbursement rates for specific codes, consult with your local Medicare contractor. 5. Federal Register/ Vol. 79, No. 163 / Friday, August 27, 2014 GE OEC Medical Systems, Inc. 384 Wright Brothers Drive Salt Lake City, UT 84116 USA www.gehealthcare.com