FOR ESSENTIAL TREMOR, PARKINSON S DISEASE, DYSTONIA AND OBSESSIVE- COMPULSIVE DISORDER EFFECTIVE JANUARY 2017 Medtronic provides this information for your convenience only. It does not constitute legal advice or a recommendation regarding clinical practice. Information provided is gathered from third-party sources and is subject to change without notice due to frequently changing laws, rules and regulations. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other payers as to the correct form of billing or the amount that will be paid to providers of service. Please contact your Medicare contractor, other payers, reimbursement specialists and/or legal counsel for interpretation of coding, coverage and payment policies. This document provides assistance for FDA approved or cleared indications. Where reimbursement is sought for use of a product that may be inconsistent with, or not expressly specified in, the FDA cleared or approved labeling (e.g. instructions for use, operator s manual or package insert), consult with your billing advisors or payers on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service. Because Medtronic DBS Therapy for dystonia and obsessive-compulsive disorder is approved for use under a Humanitarian Device Exemption (HDE), devices can be implanted only in facilities with institutional review board (IRB) approval. The following information is calculated per the footnotes included and does not take into effect Medicare payment reductions resulting from sequestration associated with the Budget Control Act of 2011. Sequestration reductions went into effect on April 1, 2013. FOR QUESTIONS PLEASE CONTACT US AT NEURO.US.REIMBURSEMENT@MEDTRONIC.COM ICD-10-CM 1 Diagnosis Codes Diagnosis codes are used by both physicians and hospitals to document the indication for the procedure. Medtronic Deep Brain Stimulation (DBS) Therapy is intended to manage the symptoms of the underlying conditions below. Because symptoms codes are generally not acceptable as the principal diagnosis, the principal diagnosis is coded to the underlying condition as shown. Essential Tremor 2 G25.0 Essential tremor Parkinson s Disease 2 G20 Parkinson s disease Dystonia Note: Humanitarian Device. The effectiveness of this device for the treatment of dystonia has not been demonstrated. G24.1 Genetic torsion dystonia (dystonia deformans progressiva) (dystonia musculorum deformans) (familial torsion dystonia) (idiopathic torsion dystonia) G24.2 Idiopathic nonfamilial dystonia (symptomatic torsion dystonia) G24.3 Spasmodic torticollis (cervical dystonia) G24.8 Other dystonia G24.9 Dystonia, unspecified Obsessive-compulsive disorder Note: Humanitarian Device. The effectiveness of this device for the treatment of obsessivecompulsive disorder has not been demonstrated. F42.2 Mixed obsessional thoughts and acts F42.8 Other obsessive-compulsive disorders F42.9 Obsessive-compulsive disorders, unspecified CHART CONTINUED ON NEXT PAGE 1
ICD-10-CM 1 Diagnosis Codes continued Device Complications 3, 4 T85.110A Breakdown (mechanical) of implanted electronic neurostimulator of brain electrode (lead) T85.113A T85.120A T85.123A T85.190A T85.193A T85.731A T85.734A T85.830A T85.840A T85.890A Breakdown (mechanical) of implanted electronic neurostimulator, generator Displacement of implanted electronic neurostimulator of brain electrode (lead) Displacement of implanted electronic neurostimulator, generator Other mechanical complication of implanted electronic neurostimulator of brain electrode (lead) Other mechanical complication of implanted electronic neurostimulator, generator Infection and inflammatory reaction due to implanted electronic neurostimulator of brain, electrode (lead) Infection and inflammatory reaction due to implanted electronic neurostimulator generator Hemorrhage due to nervous system prosthetic devices, implants and grafts Pain due to nervous system prosthetic devices, implants and grafts Other specified complication of nervous system prosthetic devices, implants and grafts 5 Attention to Device 6 Z45.42 Encounter for adjustment and management of neuropacemaker (brain, peripheral nerve, spinal cord) ICD-10-PCS 7 Procedure Codes Hospitals use ICD-10-PCS procedure codes for inpatient services. Lead Implantation 8 00H00MZ Insertion of neurostimulator lead into brain, open approach 00H03MZ Insertion of neurostimulator lead into brain, percutaneous approach Generator Implantation 9, 10, 11 0JH60BZ Insertion of single array stimulator generator into chest subcutaneous tissue and fascia, open approach 0JH60DZ 0JH60EZ Insertion of multiple array stimulator generator into chest subcutaneous tissue and fascia, open approach Insertion of multiple array rechargeable stimulator generator into chest subcutaneous tissue and fascia, open approach CHART CONTINUED ON NEXT PAGE 2
ICD-10-PCS 7 Procedure Codes continued Lead Removal 8 00P00MZ Removal of neurostimulator lead from brain, open approach 00P03MZ Removal of neurostimulator lead from brain, percutaneous approach Generator Removal 10 0JPT0MZ Removal of stimulator generator from trunk subcutaneous tissue and fascia, open approach 0JPT3MZ Removal of stimulator generator from trunk subcutaneous tissue and fascia, percutaneous approach Lead Replacement 8 or Generator Replacement 10 Two codes are required to identify a device replacement: one code for implantation of the new device and one code for removal of the old device. 12 Lead Revision 13 00W00MZ Revision of neurostimulator lead in brain, open approach 00W03MZ Revision of neurostimulator lead in brain, percutaneous approach Generator Revision 14, 15 0JWT0MZ Revision of stimulator generator in trunk subcutaneous tissue and fascia, open approach 0JWT3MZ Revision of stimulator generator in trunk subcutaneous tissue and fascia, percutaneous approach 1. Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). http:// www.cdc.gov/nchs/icd/icd10cm.htm. Updated October 1, 2016. Accessed November 30, 2016. 2. Essential tremor is treated with a single array neurostimulator generator. Parkinson s Disease is treated with a dual array neurostimulator generator. 3. When a device complication is the reason for the encounter, the device complication code is sequenced as the primary diagnosis followed by a code for the underlying condition. If the purpose of the encounter is directed toward the underlying condition or the device complication arises after admission, the underlying condition is sequenced as the primary diagnosis followed by the device complication code. 4. Device complication codes ending in A are technically defined as initial encounter but continue to be assigned for each encounter in which the patient is receiving active treatment for the complication (ICD-10-CM Official Guidelines for Coding and Reporting FY 2017, I.C.19.A). 5. According to ICD-10-CM manual notes, other specified complication includes erosion or breakdown of a subcutaneous device pocket. 6. Code Z45.42 is used as the principal diagnosis when patients are seen for routine device maintenance, such as periodic device checks and programming, as well as routine device replacement. A secondary diagnosis code is then used for the underlying condition. 7. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). http://www.cms.gov/medicare/coding/icd10/2017-icd-10-pcs-and-gems.html. Updated October 1, 2016. Accessed November 30, 2016. 8. Approach value 0-Open is used when leads are placed via craniotomy or craniectomy. Placement of a lead via burr hole is considered a percutaneous approach and uses approach value 3-Percutaneous (CMS ICD-10-PCS Reference Manual 2016, p.47). The same rationale can be applied to lead removal and replacement. 9. Codes defined as multiple array include dual array neurostimulator generators, a type of multiple array generator in which two leads are connected to one generator. Activa SC is a single-array non-rechargeable generator (device value B), Activa PC is a dual-array non-rechargeable generator (device value D), and Activa RC is a dual-array rechargeable generator (device value E). See also the ICD-10-PCS Device Index. Do not assign default device value M-Stimulator Generator. 10. Placement, removal and replacement of a neurostimulator generator is shown with the approach value 0-Open because creating the pocket requires surgical dissection and exposure. Removal also usually requires surgical dissection to free the device. 11. Body part value 6-Chest is shown because the generator is typically placed into the subcutaneous tissue of the chest. Other body part values are also available for sites such as subcutaneous tissue of abdomen and subcutaneous tissue of back. 12. CMS ICD-10-PCS Reference Manual 2016, p.67. 13. For lead revision, the ICD-10-PCS codes refer to surgical revision of the intracranial portion of the lead, eg, repositioning. For revision of the subcutaneous portion of the lead or revision of a subcutaneous extension, see Generator Revision. 14. The ICD-10-PCS codes shown can be assigned for opening the pocket for generator revision, as well as reshaping or relocating the pocket while reinserting the same generator. However, there are no ICD-10-PCS codes specifically defined for revising the subcutaneous portion of a lead or an extension. Because these services usually involve removing and reinserting the generator as well, they can also be represented by the generator revision codes. 15. Approach value X-External is also available for external generator manipulation without opening the pocket, eg. to correct a flipped generator. 3
HCPCS II Device Codes 1 These codes are used by the entity that purchased and supplied the medical device, DME, drug, or supply to the patient. For implantable devices, that is generally the facility. For specific Medicare hospital outpatient billing instructions for medical devices, see the Device C-Codes (Medicare) below. Note: The HCPCS II code for the lead is not shown because intracranial leads are not implanted on an outpatient basis. Pulse Generator 2 L8679 Implantable neurostimulator pulse generator, any type L8686 L8687 L8688 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 Patient Programmer L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only External Recharger L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only 1. Healthcare Common Procedure Coding System (HCPCS) Level II codes are maintained by the Centers for Medicare and Medicaid Services. http://www.cms.gov/medicare/coding/ MedHCPCSGenInfo/index.html Accessed November 30, 2016. 2. Effective January 2014, generator codes L8686-L8688 are not recognized 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 L8686-L8688 remain available. However, all providers should check with the payer for specific coding and billing instructions. Device C-Codes 1 (Medicare) Medicare provides C-codes for hospital use in billing Medicare for medical devices in the outpatient setting. 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 coded separately 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 Note: The C-code for the lead is not shown because intracranial leads are not implanted on an outpatient basis. Pulse Generator C1767 Generator, neurostimulator (implantable), non-rechargeable C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system Extension C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable) Patient Programmer C1787 Patient programmer, neurostimulator 1. Device C-codes are HCPCS Level II codes and are maintained by the Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System. http:// www.cms.gov/medicare/coding/hcpcsreleasecodesets/alpha-numeric-hcpcs.html. Accessed November 30, 2016. 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 implantation procedure with a single total charge, including not only the charge associated with the operating room but also the charges for the generator device 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. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14 Ambulatory Surgical Centers, Section 40. http:// www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c14.pdf. Accessed November 30, 2016. See also MLN Matters SE0742 p.9-10: Centers for Medicare and Medicaid Services. MLN Matters Number SE0742 Revised. http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/ downloads/se0742.pdf. Accessed November 30, 2016. 4
Medtronic DBS for Essen al Tremor and Parkinson s Disease DBS THERAPY Device Edits (Medicare) 1 Medicare s procedure-to-device edits require that when certain CPT procedure codes for device implantation are submitted on a hospital outpatient bill, HCPCS II codes for devices must also be billed. Effective 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 Description 3 61885 4,5 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 61886 5 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays HCPCS ll Device Codes C1767 C1767 C1820 HCPCS ll Code Description Generator, neurostimulator (implantable), non-rechargeable Generator, neurostimulator (implantable), non-rechargeable Generator, neurostimulator (implantable), with rechargeable battery and charging system 1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule.81 Fed. Reg. 79658-76959. https://www.gpo.gov/fdsys/pkg/fr-2016-11-14/pdf/2016-26515.pdf Published November 14, 2016. Accessed November 30, 2016. 2. Centers for Medicare & Medicaid Services. Device and Procedure Edits. https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/ device_procedure_archive.html. Last updated April 10, 2013. Accessed November 30, 2016. 3. CPT copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 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. 4. In practice, HCPCS device code C1820 is not appropriate with CPT procedure code 61885 because rechargeable dual-array generators are used only with procedure code 61886. 5. HCPCS II L-codes L8686-L8688 will also pass the edits, but these codes are not shown because they are not otherwise recognized by Medicare. HCPCS II device code L8679 does not satisfy the edits. 5
Physician Coding and Payment January 1, 2017 December 31, 2017 CPT Procedure Codes Physicians use CPT codes for all services. Under Medicare s Resource-Based Relative Value Scale (RBRVS) methodology for physician payment, each CPT code is assigned a point value, known as the relative value unit (RVU), which is then converted to a flat payment amount. Procedure CPT Code and Description 1 Medicare RVUs 2 Medicare National Average 3 For physician services provided in: 4 Physician Office 5 Facility Physician Office 5 Facility Bone Marker Fiducial Placement 6 Diagnostic Imaging and Planning 7,8 10, 11 Lead Implantation 70450-26 CT, head or brain; without contrast material 9 70551-26 MRI, brain (including brain stem); without contrast material 9 76376-26 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality, with image postprocessing under concurrent supervision, not requiring image post processing on an independent workstation 9 76377-26 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality, with image postprocessing under concurrent supervision, requiring image post processing on an independent workstation 9 61863 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array 61864 each additional array (List separately in addition to primary procedure.) 61867 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array 61868 each additional array (List separately in addition to primary procedure.) 1.22 $44 2.11 $76 0.28 $10 1.14 $41 N/A 44.10 N/A $1,583 N/A 8.41 N/A $302 N/A 67.00 N/A $2,405 N/A 14.77 N/A $530 CHART CONTINUED ON NEXT PAGE 6
Physician Coding and Payment continued Procedure CPT Code and Description 1 Medicare RVUs 2 Medicare National Average 3 For physician services provided in: 4 Physician Office 5 Facility Physician Office 5 Facility Generator Implantation or Replacement 10,12 61885 (Activa SC) Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array N/A 14.99 N/A $538 Intraoperative Stimulation with Microelectrode Recording 14 61886 (Activa RC, Activa PC) Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays N/A 24.63 N/A $884 For bilateral stimulation via implantation of two Activa SC single array pulse generators, one on each side connected to a single lead, use 61885-50 for the generators plus 61863 and 61864 or 61867 and 61868 for the leads. 13 For bilateral stimulation via implantation of one Activa RC or one Activa PC dual array pulse generator with connection to two leads, use 61886 for the generator plus 61863 and 61864 or 61867 and 61868 for the leads. Bilateral stimulation is not performed for essential tremor, but is performed for Parkinson s Disease. 95961-26 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of attendance by physician or other qualified healthcare professional 9 4.64 $167 95962-26 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional hour of attendance by physician or other qualified healthcare professional (List separately in addition to code for primary procedure.) 9 4.95 $178 Revision or Removal of Leads or 10,11, 12 Generator 61880 Revision or removal of intracranial neurostimulator electrodes 61888 Revision or removal of cranial neurostimulator pulse generator or receiver N/A 16.59 N/A $595 N/A 11.58 N/A $416 CHART CONTINUED ON NEXT PAGE 7
Physician Coding and Payment continued Procedure CPT Code and Description 1 Medicare RVUs 2 Medicare National Average 3 For physician services provided in: 4 Physician Office 5 Facility Physician Office 5 Facility Analysis and Programming Note: In the office, analysis and programming may be furnished by a physician, practitioner with an incident to benefit, or auxiliary personnel under the direct supervision of the physician (or other practitioner), with or without support from a manufacturer s representative. The patient or payer should not be billed for services rendered by the manufacturer s representative. Contact your local contractor or payer for interpretation of applicable policies. 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord or peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming 95971 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming 15,16 1.93 0.69 $69 $25 1.43 1.16 $51 $42 95978 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming, first hour 15,17 95979 each additional 30 minutes after first hour (List separately in addition to code for primary procedure.) 17 Note: this is a time based code 7.08 5.49 $254 $197 3.07 2.56 $110 $92 CHART CONTINUED ON NEXT PAGE 8
Physician Coding and Payment continued 1. CPT copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 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. 2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017 Final Rule; 81 Fed. Reg. 80170-80562. https://www.gpo.gov/fdsys/pkg/fr-2016-11-15/pdf/2016-26668.pdf. Published November 15, 2016. Accessed November 30, 2016. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU. 3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2017 is $35.8887 per 81 Fed. Reg. 80543. https://www.gpo.gov/fdsys/pkg/fr-2016-11-15/pdf/2016-26668.pdf. Published November 15, 2016. Accessed November 30, 2016. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017 Final Rule; Correction; 81 Fed. Reg. 95890-95892. https://www.federalregister.gov/d/2016-31649. Published December 29, 2016. Accessed January 13, 2017. See also the January 2017 release of the PFS Relative Value File RVU17A at http:/www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/pfs-relative-value-files.html. Released November 2, 2016. Accessed November 30, 2016. Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations 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 setting 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 setting 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 setting because the physician incurs all costs there. 5. N/A shown in Physician Office setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (eg, 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-1654-F. CY 2017 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. https://www.cms.gov/medicare/medicare- Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-F.html. Released November 2, 2016. Accessed November 30, 2016. 6. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate encounter, in the physician s office, and/or on a different date prior to the lead implantation. CPT Assistant, October 2010, p.9. 7. Pre-operative CT and MRI imaging may be separately coded when they represent full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately. Note that although CPT code 61781 exists for computer-assisted intradural surgical navigation, CPT manual instructions and National Correct Coding Initiative (NCCI) edits do not allow this to be coded separately with lead implantation codes 61863 and 61867. 8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure. 9. This assumes the service is occurring in the hospital facility, because the primary lead procedure must be performed in a facility. So the physician is providing the professional interpretation only (-26) and only facility RVUs and payments are displayed. 10. 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: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal. 11. When an existing lead is removed and replaced by a new lead, only the lead implantation code 61863-61867 may be assigned. For lead replacement, NCCI edits do not permit removal of the existing lead to be coded separately with placement of the new lead. 12. When an existing generator is removed and replaced by a new generator, only the generator replacement code 61885 or 61886 may be assigned. NCCI edits do not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator insertion 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. NCCI Policy Manual 1/1/2017, p. VIII-8. 13. Medicare permits the use of bilateral modifier -50 with code 61885. To show bilateral placement of two single-array generator leads, submit 61885-50 with 1 unit. Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853. http://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r1421otn.pdf. Released August 15, 2014. Accessed November 30, 2016. See also Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners, section 40.7.B. https:// www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf. Accessed November 30, 2016. See also NCCI Policy Manual 1/1/2017, p. I-41. 14. As defined, microelectrode recording is included in lead implantation codes 61867-61868. CPT manual instructions and NCCI edits do not allow 95961-95962 to be coded separately with lead implantation when microelectrode recording is performed by the operating surgeon. However, the AMA has published that when another physician (eg, neurologist or neurophysiologist) performs the cortical or subcortical mapping during the placement of the electrode array, that physician may report codes 95961-95962 separately. CPT Changes 2004: An Insider s View, p.93. 15. According to CPT manual instructions, 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 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 (eg, rigidity, dyskinesia, tremor). (See also CPT Assistant, July 2016, p.7 and p.9.) 16. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15. 17. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes. 9
Hospital Outpatient Coding and Payment Effective January 1, 2017 December 31, 2017 CPT Procedure Codes Hospitals use CPT codes for outpatient services. Under Medicare s APC methodology for hospital outpatient payment, each CPT code is assigned to one of approximately 710 ambulatory payment classes. Each APC has a relative weight that is then converted to a flat payment amount. Multiple APCs can sometimes be assigned for each encounter, depending on the number of procedures coded and whether any of the procedure codes map to a Comprehensive APC. For 2017, there are 61 APCs which are designated 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 adjunctive to delivery of the primary service. This results in a single APC payment and a single beneficiary copayment for the entire outpatient encounter, based solely on the primary service. Separate payment is not made for any of the other adjunctive services. Instead, the payment level for the C-APC is calculated to include the costs of the other adjunctive services, which are packaged into the payment for the primary service. When more than one primary service is coded for the same outpatient 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 combination of two primary services leads to a complexity adjustment in which the entire encounter is re-mapped to another higher-level APC. As shown on the tables below, DBS therapies are subject to C-APCs specifically for implantation, replacement, revision and removal of the generator. C-APCs are identified by status indicator J1. Note: Only procedures that can be performed in the hospital outpatient setting are shown. Intracranial lead implantation is not shown because it is not performed on an outpatient basis. Procedure CPT Code and Description 1 APC 2 APC Title 2 SI 2,3 Relative Weight 2 Medicare National Average 2,4 Bone Marker Fiducial Placement 5 Diagnostic Imaging 6 and Planning 70450 CT, head or brain without contrast material 7 5522 Level 2 Imaging without Contrast Q3 1.5031 $113 70551 MRI, brain (including brain stem), without contrast material 7 5523 Level 3 Imaging without Contrast Q3 3.0121 $226 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision, not requiring image postprocessing on an independent workstation 8 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision, requiring image postprocessing on an independent workstation 8 N/A N/A N N/A N/A N/A N/A N N/A N/A CHART CONTINUED ON NEXT PAGE 10
Hospital Outpatient Coding and Payment continued Procedure CPT Code and Description 1 APC 2 APC Title 2 SI 2,3 Relative Weight 2 Medicare National Average 2,4 Generator Implantation or Replacement 9 61885 (Activa SC) Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 5463 Level 3 Neurostimulator and Related Procedures J1 237.3752 $17,803 61886 (Activa RC, Activa PC) Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays 5464 Level 4 Neurostimulator and Related Procedures J1 360.6233 $27,047 For bilateral stimulation via implantation or replacement of two Activa SC single array pulse generators, one on each side connected to a single lead, use 61885-50 or 61885 plus 61885-59. 10 For bilateral stimulation via implantation or replacement of one Activa RC or one Activa PC dual array pulse generator with connection to two leads, use 61886. 11 Under Comprehensive APCs for 2017, use of 61885-50 or 61885 plus 61885-59 for the same encounter does not qualify for a complexity adjustment. When either 61885-50 is submitted or 61885 plus 61885-59 is submitted to show that two generators were placed bilaterally, the entire encounter remains under APC 5463. Revision or Removal of Leads or Generator 9 Bilateral stimulation is not performed for essential tremor, but is performed for Parkinson s Disease. 61880 Revision or removal of intracranial neurostimulator electrodes 61888 Revision or removal of cranial neurostimulator pulse generator or receiver 5461 Level 1 Neurostimulator and Related Procedures 5462 Level 2 Neurostimulator and Related Procedures Q2 35.8723 $2,690 J1 76.6005 $5,745 CHART CONTINUED ON NEXT PAGE 11
Hospital Outpatient Coding and Payment continued Procedure CPT Code and Description 1 APC 2 APC Title 2 SI 2,3 Relative Weight 2 Medicare National Average 2,4 Analysis and Programming Note: In the hospital, analysis and programming may be furnished by a physician or other practitioner, with or without support from a manufacturer s representative. Neither the payer or patient should be billed for services rendered by the manufacturer s representative. Contact your local contractor or payer for interpretation of applicable policies. 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming 95971 Electronic analysis of implanted neurostimulator pulse generator system, (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming 12,13 5734 Level 4 Minor Procedures Q1 1.3336 $100 5742 Level 2 Electronic Analysis of Devices S 1.4562 $109 95978 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/ transmitter, with initial or subsequent programming; first hour 12,14 5742 Level 2 Electronic Analysis of Devices S 1.4562 $109 95979 each additional 30 minutes after first hour (List separately in addition to code for primary procedure.) N/A N/A N N/A N/A CHART CONTINUED ON NEXT PAGE 12
Hospital Outpatient Coding and Payment continued 1. CPT copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 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. 2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems..Final Rule. 81 Fed. Reg. 79562-79892. https://www.gpo.gov/fdsys/pkg/fr-2016-11-14/pdf/2016-26515.pdf Published November 14, 2016. Accessed November 30, 2016. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule; Correction. 82 Fed. Reg. 24-37. https://www.federalregister.gov/d/2016-31774. Published January 3, 2017. Accessed January 13, 2017. 3. Status Indicator (SI) shows how a code is handled for payment purposes: J1 = paid under a comprehensive APC, single payment based on primary service without separate payment for other adjunctive services; N = packaged service, no separate payment; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higherweighted 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. See note 7 for status indicator Q3. 4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2017 is $75.001. The conversion factor of $75.001 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Reporting Program. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems... Final Rule.81 Fed. Reg. 79597. https://www.gpo.gov/fdsys/pkg/fr-2016-11-14/pdf/2016-26515.pdf. Published November 14, 2016. Accessed November 30, 2016. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule; Correction. 82 Fed. Reg. 24-37. https://www.federalregister.gov/d/2016-31774. Published January 3, 2017. Accessed January 13, 2017. Payment is adjusted by the wage index for each hospital s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. 5. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate outpatient encounter on a different date prior to the inpatient lead implantation. CPT Assistant, October 2010, p.9. Further, under Medicare s current 3-day payment window policy, all non-diagnostic services performed during the three calendar days preceding the admission are deemed related to the admission and thus must be billed with the inpatient stay. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4 Part B Hospital, Section 10.12. https://www.cms.gov/regulationsand-guidance/guidance/manuals/downloads/clm104c04.pdf. Updated April 22, 2015. Accessed November 30, 2016. Note that hospital charges related to the fiducials may be rolled into the inpatient stay. 6. Pre-operative CT and MRI imaging may be coded separately when they represent full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately. 7. More broadly, these codes have status indicator Q3. For CT and MRI, status indicator Q3 shows that the service may be part of a composite APC if billed with other similar imaging services. However, within the context of services related to Medtronic DBS Therapy, the codes will generally be paid separately under the APCs, status indicators, and rates shown. 8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure. However, they are packaged into APC payment for the base imaging and are not separately payable. 9. When an existing generator is removed and replaced by a new generator, only the generator replacement code 61885 or 61886 may be assigned. NCCI edits do not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator insertion 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. (NCCI Policy Manual 1/1/2017, p. VIII-8). 10. Medicare permits the use of bilateral modifier -50 with code 61885. To show bilateral placement of two single-array generator leads, submit 61885-50 with 1 unit. Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853. http://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r1421otn.pdf. Released August 15, 2014. Accessed November 30, 2016. See also Medicare Claims Processing Manual, Chapter 4 Part B Hospital, sections 20.6 and 20.6.2. https://www.cms.gov/ Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Accessed November 30, 2016. See also NCCI Policy Manual 1/1/2017, p. I-41. Alternately, because some payers may not recognize the bilateral modifier, providers may consider using 61885 plus 61885-59. As of October 1, 2016, Medicare s Medically Unlikely Edits allow 2 units for code 61885 on the same date of service. 11. See AHA s Coding Clinic for HCPCS, 3rd Q 2011, p.10 for bilateral stimulation via a dual array neurostimulator generator. 12. According to CPT manual instructions, 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 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, (eg, rigidity, dyskinesia, tremor). (See also CPT Assistant, July 2016, p.7 and p.9.) 13. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15. 14. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes. For hospital outpatient reporting, modifier -52 is used to indicate partial reduction of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4 Part B Hospital, Section 20.6.4.A. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c04.pdf. Updated December 18, 2015. Accessed November 30, 2016. 13
Hospital Inpatient Coding and Payment Effective October 1, 2016 September 30, 2017 MS-DRG Assignments : Essential Tremor, Parkinson s Disease, and Dystonia Under Medicare s MS-DRG methodology for hospital inpatient payment, each inpatient stay is assigned to one of about 755 diagnosis-related groups, based on the ICD-10-CM codes assigned to the diagnoses and ICD-10-PCS codes assigned to the procedures. Each MS-DRG has a relative weight that is then converted to a flat payment amount. Only one MS-DRG is assigned for each inpatient stay, regardless of the number of procedures performed. The MS-DRGs shown are those typically assigned to the following scenarios. Procedure Scenario MS- DRG 1 MS-DRG Title 1,2 Relative Weight 1 Medicare National Average 3 Implantation and Replacement : Whole System Whole system implant or replacement: - single array generator plus lead 025 Craniotomy and Endovascular Intracranial Procedures W MCC 026 Craniotomy and Endovascular Intracranial Procedures W CC 4.2413 $25,291 2.9723 $17,724 027 Craniotomy and Endovascular Intracranial Procedures W/O CC/MCC 2.3761 $14,169 Whole system implant or replacement: - multiple array nonrechargeable generator plus lead(s) - multiple array rechargeable generator plus lead(s) 023 Craniotomy with Major Device Implant/ Acute Complex CNS Principal Diagnosis W MCC or Chemo Implant 024 Craniotomy with Major Device Implant/ Acute Complex CNS Principal Diagnosis W/O MCC 5.3762 $32,058 4.0114 $23,920 Implantation and Replacement : Generator only or Lead only Generator only implant or replacement (any type) 040 Peripheral/Cranial Nerve and Other Nervous System Procedures W MCC 041 Peripheral/Cranial Nerve and Other Nervous System Procedures W CC or Peripheral Neurostimulator 3.7117 $22,133 2.1218 $12,652 042 Peripheral/Cranial Nerve and Other Nervous System Procedures W/O CC/ MCC 1.8984 $11,320 Lead only implant or replacement 025 Craniotomy and Endovascular Intracranial Procedures W MCC 4.2413 $25,291 026 Craniotomy and Endovascular Intracranial Procedures W CC 2.9723 $17,724 027 Craniotomy and Endovascular Intracranial Procedures W/O CC/MCC 2.3761 $14,169 Removal (without replacement) 4 Whole system removal: - generator (any type) plus lead(s) 5 025 Craniotomy and Endovascular Intracranial Procedures W MCC 026 Craniotomy and Endovascular Intracranial Procedures W CC 4.2413 $25,291 2.9723 $17,724 027 Craniotomy and Endovascular Intracranial Procedures W/O CC/MCC 2.3761 $14,169 CHART CONTINUED ON NEXT PAGE 14
Hospital Inpatient Coding and Payment continued MS-DRG Assignments : Essential Tremor, Parkinson s Disease, and Dystonia Procedure Scenario MS- DRG 1 MS-DRG Title 1,2 Relative Weight 1 Medicare National Average 3 Removal (without replacement) 4 Generator only removal (any type) These codes are not considered significant procedures for the purpose of DRG assignment. A non-surgical (ie, medical) DRG is assigned to the stay according to the principal diagnosis. Lead only removal 025 Craniotomy and Endovascular Intracranial Procedures W MCC 026 Craniotomy and Endovascular Intracranial Procedures W CC 027 Craniotomy and Endovascular Intracranial Procedures W/O CC/MCC Revision Lead revision 6 025 Craniotomy and Endovascular Intracranial Procedures W MCC 026 Craniotomy and Endovascular Intracranial Procedures W CC 027 Craniotomy and Endovascular Intracranial Procedures W/O CC/MCC 4.2413 $25,291 2.9723 $17,724 2.3761 $14,169 4.2413 $25,291 2.9723 $17,724 2.3761 $14,169 1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2017 Rates Final Rule, 81 Fed. Reg. 56761-57438. https://www.gpo.gov/fdsys/pkg/fr-2016-08-22/pdf/2016-18476.pdf. Published August 22, 2016. Accessed October 26, 2016. 2. W MCC in MS-DRG titles refers to secondary diagnosis codes that are designated as major complications or comorbidities. MS-DRGs W MCC have at least one major secondary complication or comorbidity. Similarly, W CC in MS-DRG titles refers to secondary diagnosis codes designated as other (non-major) complications or comorbidities, and MS-DRGs W CC have at least one other (non-major) secondary complication or comorbidity. MS-DRGs W/O CC/MCC have no secondary diagnoses that are designated as complications or comorbidities, major or otherwise. Note that some secondary diagnoses are only designated as CCs or MCCs when the conditions were present on admission, and do not count as CCs or MCCs when the conditions are acquired in the hospital during the stay. 3. Payment is based on the average standardized operating amount ($5,516.14) plus the capital standard amount ($446.79). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2017 Rates; Correction, 81 Fed. Reg. 68955. Tables 1A-1D. https://www.gpo.gov/fdsys/pkg/fr-2016-10-05/pdf/2016-24042.pdf. Published October 5, 2016. Accessed October 26, 2016 and Correction, 81 Fed. Reg. 75329. Table 1A. https://www.gpo.gov/fdsys/pkg/fr-2016-10-31/pdf/2016-26182.pdf. Published October 31, 2016. Accessed November 30, 2016. The payment rate shown is the standardized amount for facilities with a wage index greater than one. The average standard amounts shown also assume facilities 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 national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. 4. Procedures involving device removal without replacement, particularly for generators, are frequently performed as outpatient. They are shown here for the occasional scenario where removal takes place as an inpatient. 5. When the generator and leads are removed together, the lead removal code is the driver and groups to the DRGs shown. 6. For Lead Revision, the DRGs reflect surgical revision of the intracranial portion of the lead, eg, repositioning a displaced lead within brain tissue. 15