Reimbursement and Practice Management

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, the relative value unit (RVU), which is then converted to a flat payment amount.

ASCs use CPT codes for their services. Medicare payment for procedures performed in an ambulatory surgery center is based on Medicare's ambulatory patient classification (APC) methodology for hospital outpatient payment. Each CPT code designated as a covered procedure in an ASC is assigned a comparable relative weight as under the hospital outpatient APC system. This is then converted to a flat payment amount using a conversion factor unique to ASCs. Multiple procedures can be paid for each claim. Certain ancillary services, such as imaging, are also covered when they are integral to covered surgical procedures, although they may not be separately payable. In general, there is no separate payment for devices; their payment is packaged into the payment for the procedure.

Under Medicare's MS-DRG methodology for hospital inpatient payment, each inpatient stay is assigned to one of about 745 diagnosis-related groups, based on the ICD-9-CM codes assigned to the diagnoses and 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.

Hospitals use CPT codes for outpatient services. Under Medicare's APC methodology for hospital outpatient payment, each CPT code is assigned to one of about 850 ambulatory payment classes. Each APC has a relative weight that is then converted to a flat payment amount. Multiple APCs can be assigned for each claim depending on the number of procedures coded.

2012 Hospital, Physician and ASC Codes for Essential Tremor and Parkinson's Disease
2012 Hospital, Physician and ASC Codes for Dystonia*

2012 Hospital, Physician and ASC Codes for Obsessive Compulsive Disorder*

2012 Hospital, Physician and ASC Codes for Intrathecal Baclofen Therapy

2012 Hospital, Physician and ASC Codes for Intrathecal Drug Delivery

2012 Hospital, Physician and ASC Codes for the External Trialing System

2012 Hospital, Physician and ASC Codes for Gastric Electrical Stimulation

2012 Hospital, Physician and ASC Codes for Sacral Neuromodulation

2012 Hospital, Physician and ASC Codes for Spinal Cord Stimulation

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References

1. CPT Copyright 2011 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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73026-73474 (finalized November 28, 2011). The total RVU as shown here is the sum of three components: physician work RVU, 2012 transitioned 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 2012 is $34.0376. On Feb. 22 the President signed HR 3630 extending current payment calculations through Dec. 31, 2012. 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 (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73469 (finalized November 28, 2011), Addendum A: Explanation and Use of Addendum B.
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.
7. Pre-operative CT and MRI imaging is separately codable when it represents full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. 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, 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. 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.
10. 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.
11. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy effective January 2012 does not allow removal of the existing generator to be coded separately. Similarly, NCCI edits do not permit removal of an existing lead to be coded separately with placement of a new lead.
12. As defined, microelectrode recording is included in codes 61867–61868. NCCI edits do not allow 95961–95962 to be coded separately with lead implantation when microelectrode recording in performed by the operating surgeon. However, the AMA has published that when another physician (e.g., neurologist or neurophysiologist) performs the cortical or subcortical mapping during the placement of the electrode array, that physician may report codes 95961–95962 separately.
13. According to CPT manual instructions, append modifier -52 to code 95978 if programming lasts less than 31 minutes.

1. CPT Copyright 2011 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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73026-73474 (finalized November 28, 2011). The total RVU as shown here is the sum of three components: physician work RVU, 2012 transitional 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 2012 is $34.0376. On Feb. 22 the President signed HR 3630 extending current payment calculations through Dec. 31, 2012. 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 (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73469 (finalized November 28, 2011), Addendum A: Explanation and Use of Addendum B.
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.
7. Pre-operative CT and MRI imaging is separately codable when it represents full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. 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, 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 generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy effective January 2012 does not allow removal of the existing generator to be coded separately. Similarly, NCCI edits do not permit removal of an existing lead to be coded separately with placement of a new lead.
12. As defined, microelectrode recording is included in codes 61867-61868. NCCI edits do not allow 95961-95962 to be coded separately with lead implantation when microelectrode recording in performed by the operating surgeon. However, the AMA has published when another physician (e.g., neurologist or neurophysiologist) performs the cortical or subcortical mapping during the placement of the electrode array, that physician may report codes 95961–95962 separately.
13. According to CPT manual instructions, append modifier -52 to code 95978 if programming lasts less than 31 minutes.

1. CPT Copyright 2011 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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73026-73474 (finalized November 28, 2011). The total RVU as shown here is the sum of three components: physician work RVU, 2012 transitioned 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 2012 is $34.0376. On Feb. 22 the President signed HR 3630 extending current payment calculations through Dec. 31, 2012. 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 Non-facility setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office setting then it is paid using the “Facility” RVUs at the Facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73469 (finalized November 28, 2011), Addendum A: Explanation and Use of Addendum B.
6. 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 of the surgery, postoperative visits related to recovery from the surgery for 10 days, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal. Carrier-priced codes require the carrier to determine whether the global concept applies and establish the postoperative period at time of pricing.
7. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
8. This is a carrier-priced code. Carriers establish the RVUs and the payment amount, usually on an individual basis after review of the procedure report.
9. RVUs exist for this code in the non-facility (office) setting. However, they are not displayed because generator implantation and replacement customarily take place in the facility setting.
10. Medicare allows laparoscopic lead implantation 43647 and revision 438648 to be performed in the hospital outpatient setting. However, open implantation 43881 and revision 43882 of leads are permitted only as inpatient and are not payable to the hospital in the outpatient setting. If performed on an outpatient basis, the hospital will not be paid for this service. Medicare does not allow any lead procedures, laparoscopic or open, to be performed in the ASC setting. If performed in the ASC, Medicare makes no payment to the ASC.
11. According to NCCI policy, an upper GI endoscopy should not be coded separately when performed by the physician to assess the surgical field and anatomic landmarks during the same operative episode as lead implantation. The AMA has also established a coding precedent that an upper GI endoscopy should not be coded separately when the implanting physician performs it during the same operative session to confirm successful placement of the leads. In both scenarios, however, an endoscopy performed by a different physician or performed for distinct diagnostic purposes may be coded separately.

1. CPT copyright 2011 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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73026-73474 (finalized November 28, 2011). The total RVU as shown here is the sum of three components: physician work RVU, 2012 transitioned 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 2012 is $34.0376. On Feb. 22 the President signed HR 3630 extending current payment calculations through Dec. 31, 2012. 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 (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73469 (finalized November 28, 2011), Addendum A: Explanation and Use of Addendum B. “NA” shown in the Facility setting indicates that the service is not paid to the physician in a hospital or ASC, because the service is expected to be performed by employees of the hospital or ASC instead.
6. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used when a catheter is placed to administer one or more injections on a single calendar day. Code 62319 is used when the catheter is left in place to deliver the agent continuously or intermittently for more than a single calendar day.
7. Check with the payer for specific guidelines on coding a tunneled trial catheter. Options may include 62350, although the code definition specifies “long-term” and the trial is temporary, or 62319 with modifier -22 to indicate that tunneling substantially increases the work.
8. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
9. 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.
10. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. ASP values are publicly available at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice. For 2012, the payment amount is based on ASP plus 6% per 42CFR 414, SubpartK; Section 112(a) Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) and Medicare Claims Processing Manual (Chapter 17, section 20.1.3, drugs furnished incident to professional service). Check with your local Medicare contractor or other payer regarding coding and billing instructions for the KD modifier for “drug or biological infused through DME as it relates to an implanted pump.
11. Medicare generally does not pay for supplies separately. However, other payers may make a separate payment depending on the provider contract and their payment methodology.
12. Check with the payer for specific guidelines on coding fluoroscopy separately with catheter procedures. CPT manual instructions state that 77003 is assigned separately with injection codes 62311 and 62319, and NCCI edits allow this. NCCI edits also allow use of 77003 with 62350 and 62351. However, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy to place the catheter is inherent to 62350 and 62351 and should not be coded separately.
13. Use the Refill/Analysis/Programming codes only for follow-up services. NCCI edits do not allow these codes to be assigned at the time of pump implantation.
14. Code 62367 is used for pump interrogation only (e.g., determining the current programming, assessing the device’s functions such as battery voltage and settings, and retrieving or downloading stored data for review). Code 62368 is used when the pump is both interrogated and reprogrammed. Code 62369 is used when the pump is interrogated, reprogrammed and refilled by ancillary staff, eg nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician. Code 95990 and 95991 are used only the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published that pumps require reprogramming at the time of refilling.
15. The AMA has published material confirming the use of 61070 and 75809 for implanted pump catheter dye studies. However, use of 64999, unlisted procedure, nervous system, or code 95999, unlisted neurological diagnostic procedure, may be preferred by some payers.

1. CPT Copyright 2011 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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73026-73474 (finalized November 28, 2011). The total RVU as shown here is the sum of three components: physician work RVU, 2012 transitioned 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 2012 is $34.0376. On Feb. 22 the President signed HR 3630 extending current payment calculations through Dec. 31, 2012. 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 (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73469 (finalized November 28, 2011), Addendum A: Explanation and Use of Addendum B. “NA” shown in the Facility setting indicates that the service is not paid to the physician in a hospital or ASC, because the service is expected to be performed by employees of the hospital or ASC instead.
6. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used when a catheter is placed to administer one or more injections on a single calendar day. Code 62319 is used when the catheter is left in place to deliver the agent continuously or intermittently for more than a single calendar day.
7. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
8. Surgical procedures are subject to a “global period.” The global period defines other physician services which 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.
9. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. ASP values are publicly available at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice. For 2012, the payment amount is based on ASP plus 6% per 42CFR 414, SubpartK; Section 112(a) Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) and Medicare Claims Processing Manual (Chapter 17, section 20.1.3, drugs furnished incident to professional service). Check with your local Medicare contractor or other payer regarding coding and billing instructions for the KD modifier for “drug or biological infused through DME as it relates to an implanted pump.”
10. Check with the payer for specific guidelines on coding fluoroscopy separately with catheter procedures. CPT manual instructions state that 77003 is assigned separately with injection codes 62311 and 62319, and NCCI edits allow this. NCCI edits also allow use of 77003 with 62350 and 62351. However, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy to place the catheter is inherent to 62350 and 62351 and should not be coded separately.
11. Use the Refill/Analysis/Programming codes only for follow-up services. NCCI edits do not allow these codes to be assigned at the time of pump implantation.
12. Code 62367 is used for pump interrogation only (e.g., determining the current programming, assessing the device’s functions such as battery voltage and settings, and retrieving or downloading stored data for review). Code 62368 is used when the pump is both interrogated and reprogrammed. Code 62369 is used when the pump is interrogated, reprogrammed and refilled by ancillary staff, eg nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician. Code 95990 and 95991 are used only the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published that pumps require reprogramming at the time of refilling.
13. The AMA has published material confirming the use of 61070 and 75809 for implanted pump catheter dye studies. However, use of 64999, (unlisted procedure, nervous system) or code 95999 (unlisted neurological diagnostic procedure) may be preferred by some payers.

1. CPT Copyright 2011 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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73026-73474 (finalized November 28, 2011). The total RVU as shown here is the sum of three components: physician work RVU, 2012 transitioned 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 2012 is $34.0376. On Feb. 22 the President signed HR 3630 extending current payment calculations through Dec. 31, 2012. 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.
5. “N/A” shown in “Physician Office” setting indicates that Medicare has not developed RVUs in the Non-facility setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office setting, then it is paid using the “Facility” RVUs at the Facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73469 (finalized November 28, 2011), Addendum A: Explanation and Use of Addendum B.
6. 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.
7. The FDA has approved placing two temporary test stimulation leads during a single bilateral procedure. As defined and as published by the AMA, code 64561 represents a single lead, and when more than one lead is placed, each is coded separately. Medicare permits the use of bilateral modifier -50 or -LT/ -RT with code 64561. Also note that Medicare’s Medically Unlikely Edits allow 2 units for code 64561.
8. The American Urological Association has published that use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581.
9. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
10. RVUs exist for this code in the non-facility (office) setting. However, they are not displayed because generator implantation and replacement customarily take place in the facility setting.
11. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more. 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 (e.g., rigidity, dyskinesia, tremor).
12. According to CPT manual instructions, append modifier -52 to code 95972 if programming lasts less than 31 minutes.

1. CPT copyright 2011 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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73026-73474 (finalized November 28, 2011). The total RVU as shown here is the sum of three components: physician work RVU, 2012 transitioned 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 2012 is $34.0376. On Feb. 22 the President signed HR 3630 extending current payment calculations through Dec. 31, 2012. 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 (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73469 (finalized November 28, 2011), Addendum A: Explanation and Use of Addendum B.
6. As published by the AMA, these codes represent a single lead. When more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 or –L T/ –RT on these codes. Although the AMA recommends appending modifier –51 to the second code when bilateral leads are placed, this may not be recognized by payers. Some providers have been able to identify to payers that each code represents a distinct lead by appending modifier -59 to the second lead code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 and 1 unit for code 63655.
7. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 or 90 days, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
8. U se of fluoroscopy is inherent to lead implantation and should not be coded separately. This is according to guidelines published by the AMA as well as the American Association of Neurological Surgeons. In addition, National Correct Coding Initiative (NCCI) edits prohibit coding fluoroscopy separately with 63650 and 63655.
9. When an existing generator is removed and replaced by a new generator, only the generator replacement code 63685 may be assigned. NCCI policy effective January 2012 does not allow removal of the existing generator to be coded separately.
10. Code 63661 cannot be assigned for removal of a temporary trial lead that was placed percutaneously. The AMA has published that the work of removing a temporary trial lead is inherent to the original percutaneous placement code 63650 and is not coded separately. Further, codes 63661 and 63662 apply to surgical removal of permanent leads. Removal of a permanent lead by simple pull is not coded.
11. The AMA has published that replacement codes 63663 and 63664 are assigned when a permanent lead is replaced by another permanent lead via the same approach at the same spinal level. The work of removing the existing permanent lead is included and is not coded separately.
12. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, insertion codes 63655 is assigned with removal code 63661. NCCI edits allow this combination without use of a modifier.
13. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more. 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).
14. According to CPT manual instructions, append modifier -52 to code 95972 if programming lasts less than 31 minutes.

1. CPT copyright 2011 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. Medicare Program: Hospital Outpatient Prospective Payment System 76 Fed. Reg. 74122-74584 (finalized November 30, 2011).
3. Status Indicator (SI) shows how a code is handled for payment purposes: N = packaged service, no separate payment; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure; V = visit, paid at 100% of rate.
4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2012 is $70.016 as published in 76 Fed. Reg. 74190 (finalized November 30, 2011). The conversion factor of $70.016 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. 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.
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. Further, under Medicare’s current “3-day payment window” policy, all nondiagnostic services performed during the three calendar days preceding the admission “are deemed related to the admission … and must be billed with the inpatient stay” (Medicare Claims Processing Manual, Chapter 4, section 10.12).
6. 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. For Evaluation and Management, status indicator Q3 shows that the higher level clinic visits may be part of a composite APC if billed with observation 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.
7. Pre-operative CT and MRI imaging is separately codable when it represents full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. Intra-operative imaging is part of surgical navigation and should not be coded separately.
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 may be assigned. NCCI policy effective January 2012 does not allow removal of the existing generator to be coded separately.
10. According to CPT manual instructions, append modifier -52 to code 95978 if 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 (Medicare Claims Processing Manual, chapter 4, section 20.6.4.A).

1. CPT Copyright 2011 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. Medicare Program: Hospital Outpatient Prospective Payment System 76 Fed. Reg. 74122-74584 (finalized November 30, 2011).
3. Status Indicator (SI) shows how a code is handled for payment purposes: N = packaged service, no separate payment; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure; V = visit, paid at 100% of rate.
4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2012 is $70.016 as published in 76 Fed. Reg. 74190 (finalized November 30, 2011). The conversion factor of $70.016 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. 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.
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. 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 must be billed with the inpatient stay” (Medicare Claims Processing Manual, Chapter 4, section 10.12).
6. 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. For Evaluation and Management, status indicator Q3 shows that the higher level clinic visits may be part of a composite APC if billed with observation services. Otherwise, however, within the context of services related to Medtronic Reclaim® DBS Therapy for Obsessive-Compulsive Disorder, the codes will generally be paid separately under the APCs, status indicators, and rates shown.
7. Pre-operative CT and MRI imaging is separately codable when it represents full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. Intraoperative imaging is part of surgical navigation and should not be coded separately.
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 may be assigned. NCCI policy effective January 2012 does not allow removal of the existing generator to be coded separately.
10. According to CPT manual instructions, append modifier -52 to code 95978 if 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 (Medicare Claims Processing Manual, chapter 4, section 20.6.4.A).

1. CPT copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the 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.
2. Medicare Program: Hospital Outpatient Prospective Payment System, 76 Fed. Reg. 74122-74584 (finalized November 30, 2011).
3. Status Indicator (SI) shows how a code is handled for payment purposes. N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure; V = visit, paid at 100% of rate.
4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2012 is $70.016 as published in 76 Fed. Reg. 74190 (finalized November 30, 2011). The conversion factor of $70.016 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. 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. Medicare allows laparoscopic lead procedures to be performed in the hospital outpatient setting. However, open lead procedures are permitted only as inpatient and are not payable to the hospital in the outpatient setting. If performed on an outpatient basis, the hospital will not be paid for this service.
6. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
7. According to NCCI policy, an upper GI endoscopy should not be coded separately when performed by the physician to assess the surgical field and anatomic landmarks during the same operative episode as lead implantation. The AMA has also established a coding precedent that an upper GI endoscopy should not be coded separately when the implanting physician performs it during the same operative session to confirm successful placement of the leads. In both scenarios, however, an endoscopy performed for distinct diagnostic purposes may be coded separately.
8. More broadly, these codes have status indicator Q3. Status indicator Q3 shows that the higher level clinic visits may be part of a composite APC if billed with observation services. Otherwise, however, within the context of services related to neurostimulation therapy, the codes will typically be paid separately under the APCs, status indicators, and rates shown.

1. CPT Copyright 2011 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. Medicare Program: Hospital Outpatient Prospective Payment System, 76 Fed. Reg. 74122-74584 (finalized November 30, 2011).
3. Status Indicator (SI) shows how a code is handled for payment purposes. K = non-pass-through drugs, paid under separate APC; N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure; V = visit, paid at 100% of rate. See notes 13 and 14 for status indicators Q1 and Q2.
4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor 2012 is $70.016 as published in 76 Fed. Reg. 74190 (finalized November 30, 2011). The conversion factor of $70.016 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. 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. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used when a catheter is placed to administer one or more injections on a single calendar day. Code 62319 is used when the catheter is left in place to deliver the agent continuously or intermittently for more than a single calendar day.
6. Check with the payer for specific guidelines on coding a tunneled trial catheter. Options may include 62319 to reflect the temporary nature of the trial or 62350 to reflect the tunneling even though the code definition specifies “long-term.”
7. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
8. Check with the payer for specific guidelines on coding fluoroscopy separately with catheter procedures. CPT manual instructions state that 77003 is assigned separately with injection codes 62311 and 62319, and NCCI edits allow this. NCCI edits also allow use of 77003 with 62350 and 62351. However, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy to place the catheter is inherent to 62350 and 62351 and should not be coded separately. If fluoroscopy is coded, it is designated as packaged and is not separately payable.
9. J2275 is packaged and not separately payable. However, J2278 is designated as a “specified covered outpatient drug.” It is assigned to an APC and generates separate payment. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. ASP values are publicly available at http://www.cms.hhs.gov/
   McrPartBDrugAvgSalesPrice. For 2012, the payment amount is based on ASP plus 4% per Medicare Program: Hospital Outpatient Prospective Payment System 76 Fed. Reg. 74287 (finalized November 30, 2011).
10. Use the Refill/Analysis/Programming codes only for follow-up services. NCCI edits do not allow these codes to be assigned at the time of pump implantation.
11. Code 62367 is used for pump interrogation only (e.g., determining the current programming, assessing the device’s functions such as battery voltage and settings, and retrieving or downloading stored data for review). Code 62368 is used when the pump is both interrogated and reprogrammed. Code 62369 is used when the pump is interrogated, reprogrammed and refilled by hospital ancillary staff, eg nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician. Code 95990 and 95991 are used only the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published that pumps require reprogramming at the time of refilling.
12. The AMA has published material confirming the use of 61070 and 75809 for implanted pump catheter dye studies. However, use of 64999 (unlisted procedure, nervous system) or code 95999 (unlisted neurological diagnostic procedure) may be preferred by some payers.
13. Status Q2 indicates that code 75809 is conditionally packaged. Although separately payable in certain circumstances, code 75809 is designated as “packaged” into the primary service when submitted with another code with status indicator “T.” In a catheter dye study, its companion code is 61070. Because code 61070 is status “T,” code 75809 is packaged and not separately payable in this scenario.
14. Status Q1 indicates that code 76000 is conditionally packaged. Although payable in a separate APC in certain unusual circumstances, it is designated as “packaged” into the primary service when submitted with another code with status indicator “S,” “T,” “V,” or “X.” In a pump rotor study, its companion code is 62368. Because code 62368 is status “S,” code 76000 is “packaged” and not separately payable in this scenario.
15. More broadly, these codes have status indicator Q3. Status indicator Q3 shows that the higher level clinic visits may be part of a composite APC if billed with observation services. Otherwise, however, within the context of services related to intrathecal drug delivery, the codes will typically be paid separately under the APCs, status indicators, and rates shown.

1. CPT Copyright 2011 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. Medicare Program: Hospital Outpatient Prospective Payment System, 76 Fed. Reg. 74122-74584 (finalized November 30, 2011).
3. Status Indicator (SI) shows how a code is handled for payment purposes. K = non-pass-through drugs, paid under separate APC; N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure; V = visit, paid at 100% of rate. See notes 12 and 13 for status indicators Q1 and Q2.
4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2012 is $70.016 as published in 76 Fed. Reg. 74190 (finalized November 30, 2011). The conversion factor of $70.016 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. 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. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used when a catheter is placed to administer one or more injections on a single calendar day. Code 62319 is used when the catheter is left in place to deliver the agent continuously or intermittently for more than a single calendar day.
6. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
7. Check with the payer for specific guidelines on coding fluoroscopy separately with catheter procedures. CPT manual instructions state that 77003 is assigned separately with injection codes 62311 and 62319, and NCCI edits allow this. NCCI edits also allow use of 77003 with 62350 and 62351. However, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy to place the catheter is inherent to 62350 and 62351 and should not be coded separately. If fluoroscopy is coded, it is designated as packaged and is not separately payable.
8. J0475 and J0476 are both designated as a “specified covered outpatient drug.” Each is assigned to an APC and generates separate payment. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. ASP values are publicly available at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice. For 2012, the payment amount is based on ASP plus 4% per Medicare Program: Hospital Outpatient Prospective Payment System 76 Fed. Reg. 74287 (finalized November 30, 2011).
9. Use the Refill/Analysis/Programming codes only for follow-up services. NCCI edits do not allow these codes to be assigned at the time of pump implantation.
10. Code 62367 is used for pump interrogation only (e.g., determining the current programming, assessing the device’s functions such as battery voltage and settings, and retrieving or downloading stored data for review). Code 62368 is used when the pump is both interrogated and reprogrammed. Code 62369 is used when the pump is interrogated, reprogrammed and refilled by hospital ancillary staff, eg nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician. Code 95990 and 95991 are used only the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published that pumps require reprogramming at the time of refilling.
11. The AMA has published material confirming the use of 61070 and 75809 for implanted pump catheter dye studies. However, use of 64999 (unlisted procedure, nervous system) or code 95999 (unlisted neurological diagnostic procedure) may be preferred by some payers.
12. Status Q2 indicates that code 75809 is conditionally packaged. Although separately payable in certain circumstances, code 75809 is designated as “packaged” into the primary service when submitted with another code with status indicator “T.” In a catheter dye study, its companion code is 61070. Because code 61070 is status “T,” code 75809 is “packaged” and not separately payable in this scenario.
13. Status Q1 indicates that code 76000 is conditionally packaged. Although payable in a separate APC in certain unusual circumstances, it is designated as “packaged” into the primary service when submitted with another code with status indicator “S,” “T,” “V,” or “X.” In a pump rotor study, its companion code is 62368. Because code 62368 is status “S,” code 76000 is “packaged” and not separately payable in this scenario.
14. More broadly, these codes have status indicator Q3. Status indicator Q3 shows that the higher level clinic visits may be part of a composite APC if billed with observation services. Otherwise, however, within the context of services related to ITB TherapySM, the codes will typically be paid separately under the APCs, status indicators, and rates shown.

1. CPT copyright 2011 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. Medicare Program: Hospital Outpatient Prospective Payment System, 76 Fed. Reg. 74122-74584 (finalized November 30, 2011).
3. Status Indicator (SI) shows how a code is handled for payment purposes. S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher weighted T procedure; V = visit, paid at 100% of rate. See note 7 for status indicator Q1.
4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2012 is $70.016 as published in 76 Fed. Reg. 74190 (finalized November 30, 2011). The conversion factor of $70.016 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. 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 FDA has approved placing two temporary test stimulation leads during a single bilateral procedure. As defined and as published by the AMA, code 64561 represents a single lead, and when more than one lead is placed, each is coded separately. Medicare permits the use of bilateral modifier -50 or -LT/ -RT with code 64561. Also note that Medicare’s Medically Unlikely Edits allow 2 units for code 64561.
6. The American Urological Association has published that use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581.
7. Status Q1 indicates that code 76000 is conditionally packaged. Although payable in a separate APC in certain unusual circumstances, it is designated as “packaged” into the primary service when submitted with another code with status indicators “S,” “T,” “V,” or “X.” When assigned with the lead implantation code, which is status “S,” code 76000 is packaged and not separately payable.
8. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
9. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more. 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).
10. According to CPT manual instructions, append modifier -52 to code 95972 if 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 (Medicare Claims Processing Manual, chapter 4, section 20.6.4.A).
11. More broadly, these codes have status indicator Q3. Status indicator Q3 shows that the higher level clinic visits may be part of a composite APC if billed with observation services. Otherwise, however, within the context of services related to neurostimulation therapy, the codes will typically be paid separately under the APCs, status indicators, and rates shown.

1. CPT Copyright 2011 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. Medicare Program: Hospital Outpatient Prospective Payment System, 76 Fed. Reg. 74122-74584 (finalized November 30, 2011).
3. Status Indicator (SI) shows how a code is handled for payment purposes: S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure; V = visit, paid at 100% of rate.
4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2012 is $70.016 as published in 76 Fed. Reg. 74190 (finalized November 30, 2011). The conversion factor of $70.016 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. 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. As published by the AMA, these codes represent a single lead. When more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 or –L T/ –RT on these codes. Some providers have been able to identify to payers that each code represents a distinct lead by appending modifier -59 to the second lead code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 and 1 unit for code 63655.
6. U se of fluoroscopy is inherent to lead implantation and should not be coded separately. This is according to guidelines published by the AMA as well as the American Association of Neurological Surgeons. In addition, National Correct Coding Initiative (NCCI) edits prohibit coding fluoroscopy separately with 63650 and 63655.
7. When an existing generator is removed and replaced by a new generator, only the generator replacement code 63685 may be assigned. NCCI policy effective January 2012 does not allow removal of the existing generator to be coded separately.
8. Code 63661 cannot be assigned for removal of a temporary trial lead that was placed percutaneously. The AMA has published that the work of removing a temporary trial lead is inherent to the original percutaneous placement code 63650 and is not coded separately. Further, codes 63661 and 63662 apply to surgical removal of permanent leads. Removal of a permanent lead by simple pull is not coded.
9. The AMA has published that replacement codes 63663 and 63664 include the work of removing the existing permanent lead. Removal codes 63661 and 63662 are not assigned when a permanent lead is replaced by another permanent lead via the same approach at the same spinal level. The work of removing the existing permanent lead is included and is not coded separately.
10. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, insertion codes 63655 is assigned with removal code 63661. NCCI edits allow this combination without use of a modifier.
11. MAccording to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more. 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).
12. According to CPT manual instructions, append modifier -52 to code 95972 if 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 (Medicare Claims Processing Manual, chapter 4, section 20.6.4.A).
13. More broadly, these codes have status indicator Q3. Status indicator Q3 shows that the higher level clinic visits may be part of a composite APC if billed with observation services. Otherwise, however, within the context of services related to neurostimulation therapy, the codes will typically be paid separately under the APCs, status indicators, and rates shown.

1. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2011 Rates, 76 Fed. Reg. 51476 - 51846 (finalized August 18, 2011).
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/MCCs 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 ($5,209.74) plus the capital standard amount ($421.42) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2012 Rates, 76 Fed. Reg. 51797 and 51804 (finalized August 18, 2011). Note that CMS may subsequently revise these rates via a correction notice. The payment rate shown is the standardized amounts 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 your area will vary from the stated Medicare national average payment levels shown.
4. Device removal without replacement is frequently performed as an outpatient. It is shown here for the occasional scenario where removal takes place due to a complication that requires inpatient admission.

1. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2011 Rates, 76 Fed. Reg. 51476 - 51846 (finalized August 18, 2011).
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/MCCs 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 ($5,209.74) plus the capital standard amount ($421.42) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2012 Rates, 76 Fed. Reg. 51797 and 51804 (finalized August 18, 2011). Note that CMS may subsequently revise these rates via a correction notice. The payment rate shown is the standardized amounts 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 your area will vary from the stated Medicare national average payment levels shown.
4. Device removal without replacement is frequently performed as an outpatient. It is shown here for the occasional scenario where removal takes place due to a complication that requires inpatient admission. For device removal, the principal diagnosis is generally V53.02 or codes for complications of nervous system device. This results in assignment to Nervous System MS-DRGs as shown.

1. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2011 Rates, 76 Fed. Reg. 51476 - 51846 (finalized August 18, 2011).
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/MCCs 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 were acquired in the hospital during the stay.
3. Payment is based on the average standardized operating amount ($5,209.74) plus the capital standard amount ($421.42) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2012 Rates, 76Fed. Reg. 51797 and 51804 (finalized August 18, 2011). Note that CMS may subsequently revise these rates via a correction notice. The payment rate shown is the standardized amounts 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 your area will vary from the stated Medicare national average payment levels shown.
4. There are three MS-DRGs for Enterra procedures with diabetic gastroparesis as principal diagnosis: DRGs 040, 041, and 042. The difference is whether any secondary diagnoses are designated as MCCs or CCs. However, for full system neurostimulator implantation in which both the leads 04.92 and the generator 86.95 are coded, MSDRG 042 cannot be assigned. Instead, MS-DRG 041 is automatically assigned for a full system implantation regardless of whether a CC is present or not. If an MCC is also present with a full system implantation, MS-DRG 040 is assigned. For other Enterra procedures, such as lead-only implantation 04.92, the full range of MS-DRGs 040, 041, and 042 can be assigned.
5. When used as the principal diagnosis, code 536.3 is designated as a digestive system diagnosis. However, because the Enterra procedure codes are designated as nervous system procedures, the “mismatch” DRGs of 981, 982, and 983 are assigned. The DRGs are valid and payable.
6. Device removal without replacement and other revisions are typically performed as an outpatient. They are shown here for the occasional scenario where removal or revision take place due to a complication that requires inpatient admission. For coding purposes, a neurostimulator is classified as a nervous system device. When
   removed or revised for complications or because it is no longer needed, the principal diagnosis is either various nervous system complication codes or code V53.02. This results in assignment to Nervous System MS-DRGs as shown.
7. When the generator and leads are removed together, the lead removal code is the driver and groups to the DRGs shown.

1. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2011 Rates, 76 Fed. Reg. 51476 - 51846 (finalized August 18, 2011).
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/MCCs 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 were acquired in the hospital during the stay.
3. Payment is based on the average standardized operating amount ($5,209.74) plus the capital standard amount ($421.42) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2012 Rates, 76Fed. Reg. 51797 and 51804 (finalized August 18, 2011). Note that CMS may subsequently revise these rates via a correction notice. The payment rate shown is the standardized amounts 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 your area will vary from the stated Medicare national average payment levels shown.
4. The ICD-9-CM procedure codes for screening injections are not considered “significant procedures” for the purpose of MS-DRG assignment. As shown, a non-surgical (i.e., medical) DRG is assigned to the stay according to the principal diagnosis.
5. Device removal without replacement and device revision are typically performed as an outpatient. They are shown here for the occasional scenario where removal or revision take place due to a complication that requires inpatient admission. For coding purposes, an intrathecal pain pump is classified as a nervous system device. When removed or revised for complications, or because it is no longer needed, the principal diagnosis is either various nervous system complication codes or code V53.09. This results in assignment to Nervous System MS-DRGs as shown.
6. To use 03.99, removal or revision of the catheter must be surgical (i.e., by incision). Catheter removal by pull alone is not coded.

1. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2011 Rates, 76 Fed. Reg. 51476 - 51846 (finalized August 18, 2011).
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/MCCs 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 were acquired in the hospital during the stay.
3. Payment is based on the average standardized operating amount ($5,209.74) plus the capital standard amount ($421.42) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2012 Rates, 76 Fed. Reg. 51797 and 51804 (finalized August 18, 2011). Note that CMS may subsequently revise these rates via a correction notice. The payment rate shown is the standardized amounts 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 your area will vary from the stated Medicare national average payment levels shown.
4. The ICD-9-CM procedure codes for screening injections are not considered “significant procedures” for the purpose of MS-DRG assignment. As shown, a non-surgical (i.e., medical) MS-DRG is assigned to the stay according to the principal diagnosis.
5. Device removal without replacement and device revision are typically performed as an outpatient. They are shown here for the occasional scenario where removal or revision take place due to a complication that requires inpatient admission. For coding purposes, an intrathecal pump is classified as a nervous system device. When
   removed or revised for complications, or because it is no longer needed, the principal diagnosis is either various nervous system complication codes or code V53.09. This results in assignment to Nervous System MS-DRGs as shown.
6. To use 03.99, removal or revision of the catheter must be surgical (i.e., by incision). Catheter removal by pull alone is not coded.

1. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2011 Rates, 76 Fed. Reg. 51476 - 51846 (finalized August 18, 2011).
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/MCCs 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 were acquired in the hospital during the stay.
3. Payment is based on the average standardized operating amount ($5,209.74) plus the capital standard amount ($421.42) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2012 Rates, 76 Fed. Reg. 51797 and 51804 (finalized August 18, 2011). Note that CMS may subsequently revise these rates via a correction notice. The payment rate shown is the standardized amounts 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 your area will vary from the stated Medicare national average payment levels shown.
4. For InterStim for Bowel Control, DRG logic designates fecal incontinence as a digestive system diagnosis while the codes for lead implantation 04.92 and generator implantation 86.94 are designated as nervous system procedures. The result is that the “mismatch” MS-DRGs 981, 982 and 983 are assigned. These DRGs are valid and payable.
5. For InterStim for Urinary Control, DRG logic “matches” the urinary symptom diagnosis codes with lead implantation code 04.92 but not with generator implantation code 86.94. This makes lead code 04.92 the “driver” in DRG assignment, so the same MS-DRGs are assigned based on the lead code regardless of whether the generator is also implanted. However, when the generator is implanted by itself, the “mismatch” DRGs are assigned.
6. Device removal without replacement and other revisions are typically performed as an outpatient. They are shown here for the occasional scenario where removal or revision take place due to a complication that requires inpatient admission. In this scenario, a neurostimulator is classified as a nervous system device. When removed or revised for complications or because it is no longer needed, the principal diagnosis is either various nervous system complication codes or code V53.02. This results in assignment to Nervous System MS-DRGs as shown.
7. When the generator and leads are removed together, the lead removal code is the “driver” and groups to the DRGs shown.

1. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the L ong-Term Care Hospital Prospective Payment System Changes and FY2012 Rates, 76 Fed. Reg. 51476 – 51846 (finalized August 18, 2011).
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/MCCs 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 were acquired in the hospital during the stay.
3. Payment is based on the average standardized operating amount ($5,209.74) plus the capital standard amount ($421.42) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the L ong-Term Care Hospital Prospective Payment System Changes and FY2012 Rates, 76 Fed. Reg. 51797 and 51804 (finalized August 18, 2011). Note that CMS may subsequently revise these rates via a correction notice. The payment rate shown is the standardized amounts 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 your area will vary from the stated Medicare national average payment levels shown.
4. There are three MS-DRGs for spinal procedures with a nervous system principal diagnosis (DRGs 028, 029, and 030); the difference is whether secondary diagnoses are designated as MCCs or CCs. However, for full system neurostimulator implantation in which both the leads 03.93 and the generator 86.94 – 86.98 are coded, MS-DRG 030 cannot be assigned. Instead, MS-DRG 029 is automatically assigned for a full system implantation regardless of whether a CC is present or not. If an MCC is also present with a full system implantation, MS-DRG 028 is assigned. For other spinal procedures, such as lead only implantation 03.93 or lead removal 03.94, the full range of MSDRGs 028, 029, and 030 is available.
5. There are two MS-DRGs for back and neck procedures with a musculoskeletal system principal diagnosis (DRGs 490 and 491); the difference is whether secondary diagnoses are designated as CCs/MCCs. However, for full system neurostimulator implantation in which both the leads 03.93 and the generator 86.94 – 86.98 are coded, MS-DRG 490 is automatically assigned regardless of whether a CC or MCC is present. For other spinal procedures, such as lead only implantation 03.93, both MS-DRGs 490 and 491 are available.
6. The generator implantation codes are designated as nervous system procedures only. When a musculoskeletal disorder is used as the principle diagnosis, the “mismatch” DRGs of 981, 982, and 983 are assigned. The DRGs are valid and payable.
7. Device removal without replacement and other revisions are typically performed as an outpatient. They are shown here for the occasional scenario where removal or revision take place due to a complication that requires inpatient admission. For coding purposes, a neurostimulator is classified as a nervous system device. When removed or revised for complications or because it is no longer needed, the principal diagnosis is either various nervous system complication codes or code V53.02 This results in assignment to Nervous System MS-DRGs as shown.

1. CPT Copyright 2011 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. Medicare Program: Ambulatory Surgical Center Payment, 76 Fed. Reg. 74377-74451 (finalized November 30, 2011).
3. The Payment Indicator shows how a code is handled for payment purposes. A2 = surgical procedure, payment based on hospital outpatient rate adjusted for ASC; G2 = surgical procedure, non-office-based, payment based on hospital outpatient rate adjusted for ASC; J8 = device-intensive procedure, payment amount adjusted to incorporate device cost.
4. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2012 ASC conversion factor is $42.627 as published in 76 Red. Reg. 74450 (finalized November 30, 2011). Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the stated 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. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedure and 50% of the rate for the second and all subsequent procedures. These procedures are marked “Y.” However, procedures marked “N” are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures.
6. For Medicare billing, ASCs use a CMS-1500 form.
7. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy effective January 2012 does not allow removal of the existing generator to be coded separately.
8. These instructions are for Medicare claims, per the Medicare Claims Processing Manual, Chapter 14, section 40.5. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC. For non-Medicare billing, contact the payer for instructions.

1. CPT Copyright 2011 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. Medicare Program: Ambulatory Surgical Center Payment, 76 Fed. Reg. 74377-74451 (finalized November 30, 2011).
3. The Payment Indicator shows how a code is handled for payment purposes. A2 = surgical procedure, payment based on hospital outpatient rate adjusted for ASC; G2 = surgical procedure, non-office-based, payment based on hospital outpatient rate adjusted for ASC; J8 = device-intensive procedure, payment amount adjusted to incorporate device cost.
4. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2012 ASC conversion factor is $42.627 as published in 76 Red. Reg. 74450 (finalized November 30, 2011). Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the stated 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. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedure and 50% of the rate for the second and all subsequent procedures. These procedures are marked “Y.” However, procedures marked “N” are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures.
6. For Medicare billing, ASCs use a CMS-1500 form.
7. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy effective January 2012 does not allow removal of the existing generator to be coded separately.
8. These instructions are for Medicare claims, per the Medicare Claims Processing Manual, Chapter 14, section 40.5. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC. For non-Medicare billing, contact the payer for instructions.

Enterra Therapy must be performed in an IRB-approved facility.

The three codes listed are the only Enterra procedures designated as “ASC-Covered Surgical Procedures for CY 2012” for Medicare. All other Enterra procedures, including both open and laparoscopic lead procedures, are not on Medicare’s list of covered ASC procedures. If these procedures are performed in an ASC, Medicare makes no payment to the facility and the beneficiary is personally liable for the facility charges. Medicare’s list of covered surgical procedures is available at: http://www.cms.hhs.gov/ASCPayment/.


1. CPT copyright 2011 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. Medicare Program: Ambulatory Surgical Center Payment, 76 Fed. Reg. 74377-74451 (finalized November 30, 2011).
3. The Payment Indicator shows how a code is handled for payment purposes. A2 = surgical procedure, payment based on hospital outpatient rate adjusted for ASC; J8 = device-intensive procedure, payment amount adjusted to incorporate device cost.
4. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2012 ASC conversion factor is $42.627 as published in 76 Red. Reg. 74450 (finalized November 30, 2011). Payment is adjusted by the wage index for each ASC’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. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for additional procedures. Procedures subject to discounting are marked “Y.” Procedures marked “N” are not subject to discounting and always pay at 100% of the rate regardless of whether they are submitted with other procedures.
6. For Medicare billing, ASCs use a CMS-1500 form.
7. According to NCCI policy, an upper GI endoscopy should not be coded separately when performed by the physician to assess the surgical field and anatomic landmarks during the same operative episode as lead implantation. The AMA has also established a coding precedent that an upper GI endoscopy should not be coded separately when the implanting physician performs it during the same operative session to confirm successful placement of the leads. In both scenarios, however, an endoscopy performed for distinct diagnostic purposes may be coded separately.

1. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2011 Rates, 76 Fed. Reg. 51476 - 51846 (finalized August 18, 2011).
2. AW 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/MCCs have no secondary diagnoses that are designated as complications or comorbidities, major or otherwise.
3. Payment is based on the average standardized operating amount ($5,209.74) plus the capital standard amount ($421.42) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2012 Rates, 76 Fed. Reg. 51797 and 51804 (finalized August 18, 2011). Note that CMS may subsequently revise these rates via a correction notice. The payment rate shown is the standardized amounts 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 your area will vary from the stated Medicare national average payment levels shown.
4. The ICD-9-CM procedure codes for screening injections are not considered “significant procedures” for the purpose of MS-DRG assignment. As shown, a non-surgical (i.e., medical) DRG is assigned to the stay according to the principal diagnosis.
5. Device removal without replacement and device revision are typically performed as an outpatient. They are shown here for the occasional scenario where removal or revision take place due to a complication that requires inpatient admission. For coding purposes, an intrathecal pain pump is classified as a nervous system device. When removed or revised for complications or because it is no longer needed, the principal diagnosis is either various nervous system complication codes or code V53.09. This results in assignment to Nervous System MS-DRGs as shown.
6. To use 03.99, removal or revision of the catheter must be surgical (i.e., by incision). Catheter removal by pull alone is not coded.

1. CPT Copyright 2011 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. Medicare Program: Ambulatory Surgical Center Payment, 76 Fed. Reg. 74377-74451 (finalized November 30, 2011).
3. The Payment Indicator shows how a code is handled for payment purposes. A2 = surgical procedure, payment based on hospital outpatient rate adjusted for ASC; J8 = device-intensive procedure, payment amount adjusted to incorporate device cost; K2 = drugs paid separately when provided integral to a surgical procedure on ASC list; N1 = packaged service, no separate payment; P3 = office-based procedure, payment based on physician fee schedule.
4. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2012 ASC conversion factor is $42.627 as published in 76 Red. Reg. 74450 (finalized November 30, 2011). Payment is adjusted by the wage index for each ASC’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. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for the second and all subsequent procedures. These procedures are marked “Y.” However, procedures marked “N” are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures.
6. For Medicare billing, ASCs use a CMS-1500 form.
7. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used when a catheter is placed to administer one or more injections on a single calendar day. Code 62319 is used when the catheter is left in place to deliver the agent continuously or intermittently for more than a single calendar day.
8. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
9. Check with the payer for specific guidelines on coding fluoroscopy separately with catheter procedures. CPT manual instructions state that 77003 is assigned separately with injection codes 62311 and 62319, and NCCI edits allow this. NCCI edits also allow use of 77003 with 62350 and 62351. However, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy to place the catheter is inherent to 62350 and 62351 and should not be coded separately. If fluoroscopy is coded, it is packaged into the payment for catheter placement and is not separately payable.
10. Although most drugs are packaged and not separately payable, both code J0475 and code J0476 are designated as an “ASC covered ancillary service integral to covered surgical procedures for Calendar Year 2012 and both codes generate separate payment. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. ASP values are publicly available at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice. For 2012, the payment amount is based on ASP plus 4% per 76 Fed. Reg. 74287 (finalized November 30, 2011).
11. Use the Refill/Analysis/Programming codes only for follow-up services. NCCI edits do not allow these codes to be assigned at the time of pump implantation.
12. Code 62367 is used for pump interrogation only (e.g., determining the current programming, assessing the device’s functions such as battery voltage and settings, and retrieving or downloading stored data for review). Code 62368 is used when the pump is both interrogated and reprogrammed. Code 62369 is used when the pump is interrogated, reprogrammed and refilled by facility ancillary staff, eg nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician.

1. The surgical codes listed are designated as ASC-Covered Surgical Procedures for CY 2012 for Medicare. Code 76000 is designated an “ASC-Covered Ancillary Services Integral to Covered Surgical Procedures.” Medicare’s list of covered surgical procedures and ancillary services is available at: http://www.cms.hhs.gov/ASCPayment/.
2. CPT copyright 2011 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.
3. Medicare Program: Ambulatory Surgical Center Payment, 76 Fed. Reg. 74377-74451 (finalized November 30, 2011).
4. A2 = surgical procedure, payment based on hospital outpatient rate adjusted for ASC; J8 = device-intensive procedure, payment amount adjusted to incorporate device cost; N1 = packaged service, no separate payment.
5. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. TThe 2012 ASC conversion factor is $42.627 as published in 76 Red. Reg. 74450 (finalized November 30, 2011). Payment is adjusted by the wage index for each ASC’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.
6. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for the second and all subsequent procedures. These procedures are marked “Y.” However, procedures marked “N” are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures.
7. For Medicare billing, ASCs use a CMS-1500 form.
8. The FDA has approved placing two temporary test stimulation leads during a single bilateral procedure. As defined and as published by the AMA, code 64561 represents a single lead and when more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 for payment in the ASC and instructs that bilateral procedures should be reported with the CPT procedure code repeated on two separate lines, or reported on a single line with units of “2” (see the Medicare Claims Processing Manual, Chapter 14, section 40.5). ASCs may be able to identify distinct leads to the payer by using two separate lines and appending modifier -59 to the second lead insertion code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 64561.
9. The American Urological Association has published that use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581.
10. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
     

1. CPT Copyright 2011 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. Medicare Program: Ambulatory Surgical Center Payment, 76 Fed. Reg. 74377-74451 (finalized November 30, 2011).
3. The Payment Indicator shows how a code is handled for payment purposes. A2 = surgical procedure, payment based on hospital outpatient rate adjusted for ASC; G2 = surgical procedure, non-office-based, payment based on hospital outpatient rate adjusted for ASC; J8 = device-intensive procedure, payment amount adjusted to incorporate device cost.
4. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2012 ASC conversion factor is $42.627 as published in 76 Red. Reg. 74450 (finalized November 30, 2011). Payment is adjusted by the wage index for each ASC’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. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedure and 50% of the rate for the second and all subsequent procedures. These procedures are marked “Y.” However, procedures marked “N” are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures.
6. For Medicare billing, ASCs use a CMS-1500 form.
7. As published by the AMA, these codes represent a single lead. When more than one lead is placed, each is coded separately. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC and instructs that bilateral procedures should be reported with the CPT procedure code repeated on two separate lines, or reported on a single line with units of “2” (see the Medicare Claims Processing Manual, Chapter 14, section 40.5). ASCs may be able to identify distinct leads to the payer by using two separate lines and appending modifier -59 to the second lead insertion code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 and 1 unit for code 63655.
8. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy effective January 2012 does not allow removal of the existing generator to be coded separately.
9. Code 63661 cannot be assigned for removal of a temporary trial lead that was placed percutaneously. The AMA has published that the work of removing a temporary trial lead is inherent to the original percutaneous placement code 63650 and is not coded separately. Further, codes 63661 and 63662 apply to surgical removal of permanent leads. Removal of a permanent lead by simple pull is not coded.
10. The AMA has published that replacement codes 63663 and 63664 are assigned when a permanent lead is replaced by another permanent lead via the same approach at the same spinal level. The work of removing the existing permanent lead is included and is not coded separately.
11. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, insertion codes 63655 is assigned with removal code 63661. NCCI edits allow this combination without use of a modifier.