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Reimbursement and Practice Management

Reimbursement

Coding Information

Select a therapy below to view commonly billed codes for a particular procedure or device:

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.This information is calculated per the footnotes included and does not take into effect Medicare payment reductions resulting from sequestration associated with the Budget Control Act of 2011. Sequestration reductions went into effect on April 1, 2013.

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.This information is calculated per the footnotes included and does not take into effect Medicare payment reductions resulting from sequestration associated with the Budget Control Act of 2011. Sequestration reductions went into effect on April 1, 2013.

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.This information is calculated per the footnotes included and does not take into effect Medicare payment reductions resulting from sequestration associated with the Budget Control Act of 2011. Sequestration reductions went into effect on April 1, 2013.

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 870 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.This information is calculated per the footnotes included and does not take into effect Medicare payment reductions resulting from sequestration associated with the Budget Control Act of 2011. Sequestration reductions went into effect on April 1, 2013.

This information is calculated per the footnotes included and does not take into effect Medicare payment reductions resulting from sequestration associated with the Budget Control Act of 2011. Sequestration reductions went into effect on April 1, 2013.

 

References
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed. Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014. (The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.)
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Accessed November 13, 2014.
  6. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate encounter, in the physician’s office, and/or on a different date prior to the lead implantation. CPT Assistant, October 2010, p.9.
  7. Pre-operative CT and MRI imaging may be separately coded when they represent full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately. Note that although CPT code 61781 exists for computer-assisted intradural surgical navigation, CPT manual instructions and National Correct Coding Initiative (NCCI) edits do not allow this to be coded separately with lead implantation codes 61863 and 61867.
  8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure.
  9. This assumes the service is occurring in the hospital facility, because the primary lead procedure must be performed in a facility. So the physician is providing the professional interpretation only (-26) and only facility RVUs and payments are displayed.
  10. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed, or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  11. In a lead replacement, NCCI edits do not permit removal of an existing lead to be coded separately with placement of a new lead.
  12. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  13. As defined, microelectrode recording is included in codes 61867 - 61868. CPT manual instructions and NCCI edits do not allow 95961 - 95962 to be coded separately with lead implantation when microelectrode recording is performed by the operating surgeon. However, the AMA has published that when another physician (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. CPT Changes 2004: An Insider’s View, p.93.
  14. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature (e.g., rigidity, dyskinesia, tremor).
  15. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15.
  16. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed. Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014. (The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.)
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Accessed November 13, 2014.
  6. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate encounter, in the physician’s office, and/or on a different date prior to the lead implantation. CPT Assistant, October 2010, p.9.
  7. Pre-operative CT and MRI imaging may be separately codable when it represents full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately. Note that although CPT code 61781 exists for computer-assisted intradural surgical navigation, CPT manual instructions and National Correct Coding Initiative (NCCI) edits do not allow this to be coded separately with lead implantation codes 61863 and 61867.
  8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure.
  9. This assumes the service is occurring in the hospital facility, because the primary lead procedure must be performed in a facility. So the physician is providing the professional interpretation only (-26) and only facility RVUs and payments are displayed.
  10. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed, or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  11. In a lead replacement, NCCI edits do not permit removal of an existing lead to be coded separately with placement of a new lead.
  12. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  13. As defined, microelectrode recording is included in codes 61867 - 61868. CPT manual instructions and NCCI edits do not allow 95961 - 95962 to be coded separately with lead implantation when microelectrode recording is performed by the operating surgeon. However, the AMA has published that when another physician (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. CPT Changes 2004: An Insider’s View, p.93.
  14. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature (e.g., rigidity, dyskinesia, tremor).
  15. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15.16. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014. (The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.)
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Published November 13, 2014. Accessed November 17, 2014.
  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. Contractor-priced codes require the payer to determine whether the global concept applies and to establish the postoperative period at time of pricing.
  7. For lead replacement, National Correct Coding Initiative (NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  8. Although two leads are implanted, these codes are assigned just once. The published vignettes for lead implantation codes 43647 and 43881 include two leads, and Medicare’s Medically Unlike Edits allow just 1 unit for code 43647 and just 1 unit for code 43881.
  9. Although payable to the physician as determined by the contractor, Medicare restricts corresponding payment to the facility by site of service. Medicare allows laparoscopic lead implantation 43647 and revision 43648 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.
  10. For Medicare, this is a contractor-priced code. Contractors establish the RVUs and the payment amount, usually on an individual basis after review of the procedure report.
  11. RVUs exist for this code in the office setting. However, they are not displayed because generator implantation and replacement customarily take place in the facility setting.
  12. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  13. According to NCCI policy and AMA coding precedent, an EGD should not be coded separately when performed by the physician to assess the surgical field and anatomic landmarks or to confirm successful lead placement during the same operative episode as lead implantation. In both scenarios, however, an EGD performed by a different physician or performed for distinct diagnostic purposes may be coded separately.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014. (The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.)
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. “N/A” 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C.http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Published November 13, 2014. Accessed November 17, 2014.
  6. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited because codes 62311 and 62319 are already valued to include fluoroscopic guidance. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  8. 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.
  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, 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. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  11. Payer interpretations on coding, billing and payment for the drug may vary. For coding and billing, some contractors instruct that modifier -KD, defined “drug or biological infused through DME”, be appended to the drug code when the drug is infused via an implanted pump. However, other contractors instruct the modifier -KD is reserved for external pumps and should not be appended for drugs infused via an implanted pump. For payment, some contractors make payment for the drug at 95% of AWP and others make payment at ASP + 6%. (ASP and AWP values are available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. and are updated quarterly.) Providers should check with the local Medicare contractor or other payers for their specific coding, billing and payment instructions.
  12. 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.
  13. Use the Refill/Analysis/Reprogramming 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 assigned 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 assigned when the pump is both interrogated and reprogrammed.
  15. Code 62369 is assigned when the pump is interrogated, reprogrammed and refilled by ancillary staff, eg. nurse under physician supervision in the office. Although RVUs exist for code 62369 in the facility setting, they are not displayed because the service is typically provided by facility staff, eg. hospital nurse. As defined, code 62370 is used when the pump is interrogated, reprogrammed, and refilled by a physician or “other qualified health care professional”. The AMA defines “other qualified health care professional” as an individual who performs professional services within their scope of practice and is able to bill their services independently, eg. nurse practitioner.
  16. Codes 95990 and 95991 are used only when the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published (CPT Assistant, July 2006, p.2) that programmable pumps require reprogramming at the time of refilling. For this reason, codes 95990 and 95991 are generally used for refilling and maintenance of non-programmable pumps.
  17. The AMA has published material (CPT Assistant, September 2008, p.10) confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  18. RVUs exist for this code in the office setting. However, they are not displayed because the professional component –26 is customarily provided in the facility setting.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. “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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Published November 13, 2014. Accessed November 17, 2014
  6. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited because codes 62311 and 62319 are already valued to include fluoroscopic guidance. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  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, treatment of complications unless they require a return visit to the operating room, and minor post– operative services such as dressing changes and suture removal.
  9. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device
  10. Payer interpretations on coding, billing and payment for the drug may vary. For coding and billing, some contractors instruct that modifier -KD, defined “drug or biological infused through DME”, be appended to the drug code when the drug is infused via an implanted pump. However, other contractors instruct the modifier -KD is reserved for external pumps and should not be appended for drugs infused via an implanted pump. For payment, some contractors make payment for the drug at 95% of AWP and others make payment at ASP + 6%. (ASP and AWP values are available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html and are updated quarterly.) Providers should check with the local Medicare contractor or other payers for their specific coding, billing and payment instructions.
  11. Use the Refill/Analysis/Reprogramming 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 assigned 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 assigned when the pump is both interrogated and reprogrammed.
  13. Code 62369 is assigned when the pump is interrogated, reprogrammed and refilled by ancillary staff, eg. nurse under physician supervision in the office. Although RVUs exist for code 62369 in the facility setting, they are not displayed because the service is typically provided by facility staff, eg. hospital nurse. As defined, code 62370 is used when the pump is interrogated, reprogrammed, and refilled by a physician or “other qualified health care professional”. The AMA defines “other qualified health care professional” as an individual who performs professional services within their scope of practice and is able to bill their services independently, eg. nurse practitioner.
  14. Codes 95990 and 95991 are used only when the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published (CPT Assistant, July 2006, p.2) that programmable pumps require reprogramming at the time of refilling. For this reason, codes 95990 and 95991 are generally used for refilling and maintenance of non-programmable pumps.
  15. The AMA has published material (CPT Assistant, September 2008, p.10) confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  16. RVUs exist for this code in the office setting. However, they are not displayed because the professional component –26 is customarily provided in the facility setting.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule 79 Fed. Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 17, 2014. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Published November 13, 2014. Accessed November 17, 2014.
  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 (CPT Assistant, December 2008, p.8-9), code 64561 represents a single lead, and when more than one lead is placed, each is coded separately. Medicare does permit the use of bilateral modifier -50 with code 64561. Medicare’s Medically Unlikely Edits allow 1 unit for code 64561 on the same date of service. To show placement of two test leads, submit 64561-50 with 1 unit. (Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf. Released August 15, 2014. Accessed November 17, 2014.)
  8. National Correct Coding Initiative (NCCI) policy and edits do not allow HCPCS II test lead code A4290 to be submitted with procedure code 64561, because code 64561 is already valued to include the test lead.
  9. As defined and as published by the AMA (CPT Assistant, December 2008, p.8-9), code 64581 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 or –L T/ –RT with code 64581. Some payers recognize that each code represents a distinct lead when modifier –51 or modifier –59 is appended to the additional code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 64581 on the same date of service.
  10. Because the definition of code 64561 includes image guidance, use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. (See also CPT Assistant, September 2014, p.5.) Similarly, NCCI edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581.
  11. RVUs exist for this code in the office setting. However, they are not displayed because the professional component –26 is customarily provided in the facility setting.
  12. For lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  13. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  14. RVUs exist for this code in the office setting. However, they are not displayed because generator implantation and replacement customarily take place in the facility setting.
  15. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature.
  16. According to CPT manual instructions, append modifier -52 for reduced services to code 95972 if complex programming lasts less than 31 minutes.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule 79 Fed. Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 17, 2014. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Published November 13, 2104. Accessed November 17, 2014.
  4. As defined and as published by the AMA (CPT Assistant, June 1998, p.4), these codes represent a single lead. When more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 or –L T/ –RT on these codes. Some payers recognize that each code represents a distinct lead when modifier –51 or modifier –59 is appended to the additional codes. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 on the same date of service, but only 1 unit for code 63655. Denials for units in excess of the MUE values may be appealed.
  5. 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 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.
  6. The published vignettes for codes 63650 and 63655 include fluoroscopy and, according to guidelines published by the American Association of Neurological Surgeons (AANS Guide to Coding, 2012 Edition, p.66), its use is inherent to lead implantation and should not be coded separately. In addition, National Correct Coding Initiative (NCCI) edits prohibit coding fluoroscopy separately with 63650 and 63655.
  7. The Physician Office RVUs for code 63650 are valued to include payment for the lead and other practice expenses associated with office-based trials. HCPCS code L8680 should not be reported separately for the lead in conjunction with office-based trials.
  8. The AMA has published (CPT Assistant, October 2013, p.19) that use of an incision to admit the needle or to anchor the lead is inherent to percutaneous placement and does not alter use of code 63650.
  9. When an existing generator is removed and replaced by a new generator, only the generator replacement code 63685 may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  10. 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. Code 63661 cannot be assigned for removal of a temporary trial lead that was placed percutaneously. Further, codes 63661 and 63662 apply to surgical removal of permanent leads . Removal of a permanent lead by simple pull is not coded (CPT Assistant, August 2010, p.8,15; April 2011,p.10-11,15).
  11. The AMA has published that replacement codes 63663 and 63664 are assigned when a permanent lead is replaced by another permanent lead of the same type via the same approach at the same spinal level. The work of removing the existing permanent lead is included and is not coded separately (CPT Assistant, August 2010, p.8,15; April 2011,p.10-11,15).
  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 code 63655 is assigned with removal code 63661 (CPT Assistant, April 2011,p.11,15). 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 parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature.
  14. According to CPT manual instructions
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure; J1 = paid under a comprehensive APC, single payment based on primary service without separate payment for other adjunctive services. See note 7 for status indicator Q3.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate outpatient encounter on a different date prior to the inpatient lead implantation. CPT Assistant, October 2010, p.9. Further, under Medicare’s current “3-day payment window” policy, all non-diagnostic services performed during the three calendar days preceding the admission “are deemed related to the admission and thus must be billed … with the inpatient stay”. Medicare Claims Processing Manual, Chapter 4, section 10.12. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 10.12. http://ww.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated February 7, 2014. Accessed November 11, 2014. Note that hospital charges related to the fiducials may be rolled into the inpatient stay.
  6. Pre-operative CT and MRI imaging may be coded separately when they represent full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately.
  7. More broadly, these codes have status indicator Q3. For CT and MRI, status indicator Q3 shows that the service may be part of a composite APC if billed with other similar imaging services. However, within the context of services related to Medtronic DBS Therapy, the codes will generally be paid separately under the APCs, status indicators, and rates shown.
  8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure. However, they are packaged into APC payment for the base imaging and are not separately payable.
  9. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  10. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature, (e.g., rigidity, dyskinesia, tremor).
  11. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15.
  12. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes. For hospital outpatient reporting, modifier -52 is used to indicate partial reduction of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 20.6.4.A. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated January 13, 2012. Accessed November 11, 2014
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure; J1 = paid under a comprehensive APC, single payment based on primary service without separate payment for other adjunctive services. See note 7 for status indicator Q3.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. http://ww.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated February 7, 2014. Accessed November 11, 2014. Note that hospital charges related to the fiducials may be rolled into the inpatient stay.
  5. Pre-operative CT and MRI imaging may be coded separately when they represent full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately.
  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. 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. 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.
  8. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  9. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature, (e.g., rigidity, dyskinesia, tremor).
  10. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15.
  11. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes. For hospital outpatient reporting, modifier -52 is used to indicate partial reduction of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 20.6.4.A. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated January 13, 2012. Accessed November 11, 2014.
  1. CPT copyright 2014 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure, Q2 = T packaged codes, not paid separately when billed with a T procedure; .J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.

    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 lead replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  7. Although two leads are implanted, code 43647 is assigned just once. The code’s published vignette includes two leads, and Medicare’s Medically Unlike Edits allow just 1 unit for code 43647.
  8. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  9. When generator implantation is coded and billed together with lead implantation, for example 64590 plus 43647, the entire encounter continues to map to the APC for generator implantation. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the lead.
  10. According to NCCI policy and AMA coding precedent, an EGD should not be coded separately when performed by the physician to assess the surgical field and anatomic landmarks or to confirm successful lead placement during the same operative episode as lead implantation. In both scenarios, however, an EGD performed for distinct diagnostic purposes may be coded separately.
  1. CPT Copyright 2014 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. CCenters for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; N = packaged service, no separate payment; J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services; K = non-pass-through drugs, paid under separate APC unless submitted with J1. See notes 10 and 17 for status indicator Q2.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  7. 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.”
  8. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  9. When pump implantation is coded and billed together with catheter implantation, ie, 62362 plus 62350, the entire encounter continues to map to the APC for pump implantation. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the catheter.
  10. Status Q2 indicates that device removal codes 62355 and 62365 are conditionally packaged. When submitted with another code with status “T”, such as the catheter implantation code 62350 or catheter dye study code 61070, the device removal codes are packaged into the primary service and are not separately payable. However, a device removal code is separately payable when it is the only procedure performed. When both device removal codes 62355 and 62365 are performed together, with no other procedures, then higher-weighted code 62365 is paid and lower-weighted code 62355 is packaged and not separately payable.
  11. Code J2274 is packaged and not separately payable. However, except in one specific scenario (see note 12), code J2278 is designated as a “specified covered outpatient drug.” It is assigned to an APC and generates separate payment. ASP values are publicly available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. For 2015, the payment amount is based on ASP plus 6%. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66891. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  12. Code J2278 is not paid separately when the pump is filled with Ziconotide during the same encounter as when the pump is implanted. Because pump implantation code 62362 maps to a C-APC and is status J1, there is no separate payment for adjunctive services such as higher cost drugs (see also Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66800, 66808. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.)
  13. Use the Refill/Analysis/Reprogramming 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 hospital ancillary staff, eg nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician or equivalent.
  15. Code 95990 and 95991 are used only when the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published (CPT Assistant, July 2006, p.2) that programmable pumps require reprogramming at the time of refilling. For this reason, codes 95990 and 95991 are generally used for refilling and maintenance of non-programmable pumps.
  16. The AMA has published material (CPT Assistant, September 2008, p.10) confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  17. Status Q2 indicates that code 75809 is conditionally packaged. Although separately payable in certain unusual circumstances, it 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.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services; K = non-pass-through drugs, paid under separate APC unless submitted with J1. See notes 12 and 19 for status indicator Q2. See note 7 for status indicator A.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.

    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. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  7. The physician performs the injection itself. The hospital-employed physical therapist performs the baseline evaluation and periodic assessments over the course of 6 to 8 hours to gauge the effectiveness of the ITB therapy, outside of standard evaluation for any complications and routine recovery from the injection. Under APCs, physical therapy services billed by a hospital are status A. A = services furnished to a hospital outpatient that are paid separately under a different fee schedule. Physical therapy services billed by a hospital are paid to the hospital using fees from the Physician Fee Schedule.
  8. Use of code 97001 for the ITB screening test assumes that prior evaluation had not been performed. The PT must document the impairment as well as all conditions and complexities that may impact the treatment, the current functional status, objective measurements, clinical judgments, a determination of whether or not the therapy could be useful, and a prognosis for benefit.
  9. Use of code 97750 for the periodic assessments reflects additional objective documentation of a patient’s condition or status, usually performed every two hours after the injection. Observational assessment may be included but hands-on measurement is required. These type of tests include isokinetic testing, functional capacity evaluation, and gait and balance assessments, including the Ashworth scale. A distinct report is required, documenting the specific test performed, the time spent, and the test results as well as how results could impact treatment planning.
  10. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  11. When pump implantation is coded and billed together with catheter implantation, ie, 62362 plus 62350, the entire encounter continues to map to the APC for pump implantation. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the catheter.
  12. Status Q2 indicates that device removal codes 62355 and 62365 are conditionally packaged. When submitted with another code with status “T”, such as the catheter implantation code 62350 or catheter dye study code 61070, the device removal codes are packaged into the primary service and are not separately payable. However, a device removal code is separately payable when it is the only procedure performed. When both device removal codes 62355 and 62365 are performed together, with no other procedures, then higher-weighted code 62365 is paid and lower-weighted code 62355 is packaged and not separately payable.
  13. Except in one specific scenario (see note 14), J0475 and J0476 are both designated as a “specified covered outpatient drug.” Each is assigned to an APC and generates separate payment. ASP values are publicly available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. For 2015, the payment amount is based on ASP plus 6% (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66891. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. Published November 10, 2014. Accessed November 11, 2014.
  14. Code J0475 is not paid separately when the pump is filled with baclofen during the same encounter as when the pump is implanted. Because pump implantation code 62362 maps to a C-APC and is status J1, there is no separate payment for adjunctive services such as higher cost drugs (see also Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66800, 66808. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. Published November 10, 2014. Accessed November 11, 2014.)
  15. Use the Refill/Analysis/Reprogramming codes only for follow-up services. NCCI edits do not allow these codes to be assigned at the time of pump implantation.
  16. 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 a physician or equivalent.
  17. Codes 95990 and 95991 are used only when the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published (CPT Assistant, July 2006, p.2) that programmable pumps require reprogramming at the time of refilling. For this reason, codes 95990 and 95991 are generally used for refilling and maintenance of non-programmable pumps.
  18. The AMA has published material (CPT Assistant, September 2008, p.10) confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  19. Status Q2 indicates that code 75809 is conditionally packaged. Although separately payable in certain unusual circumstances, it 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.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure, Q2 = T packaged codes, not paid separately when billed with a T procedure; .J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.

    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 (CPT Assistant, December 2008, p.8-9), code 64561 represents a single lead, and when more than one lead is placed, each is coded separately. Medicare does permit the use of bilateral modifier -50 with code 64561. Medicare’s Medically Unlikely Edits allow 1 unit for code 64561 on the same date of service. To show placement of two test leads, submit 64561-50 with 1 unit. (Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf. Released August 15, 2014. Accessed November 17, 2014.)
  6. When bilateral implantation of two percutaneous test leads is coded and billed, ie. 64561-50, the entire encounter continues to map to APC 0061. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the second lead.
  7. As defined and as published by the AMA (CPT Assistant, December 2008, p.8-9), code 64581 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 or –L T/ –RT with code 64581. Payers recognize that each code represents a distinct lead when modifier –59 is appended to the additional code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 64581 on the same date of service.
  8. Because the definition of code 64561 includes image guidance, use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. (See also CPT Assistant, September 2014, p.5.) Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581
  9. For lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  10. When generator implantation is coded and billed together with lead implantation, ie. 64590 plus 64581, the entire encounter continues to map to the APC for generator implantation. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the lead.
  11. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  12. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  13. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature.
  14. According to CPT manual instructions, append modifier -52 for reduced services to code 95972 if complex programming lasts less than 31 minutes. For hospital outpatient reporting, modifier -52 is used to indicate partial reduction of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 20.6.4.A. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf". Accessed November 11, 2014.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure ; J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.

    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 defined and as published by the AMA (CPT Assistant, June 1998, p.4), these codes represent a single lead, and when more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 or –L T/ –RT on these codes. Some payers recognize that each code represents a distinct lead when modifier –59 is appended to the additional codes. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 on the same date of service, but only 1 unit for code 63655. Denials for units in excess of the MUE values may be appealed.
  6. The published vignettes for codes 63650 and 63655 include fluoroscopy and, according to guidelines published by the American Association of Neurological Surgeons (AANS Guide to Coding, 2012 Edition, p.66), its use is inherent to lead implantation and should not be coded separately. In addition, National Correct Coding Initiative (NCCI) edits prohibit coding fluoroscopy separately with 63650 and 63655.
  7. The AMA has published (CPT Assistant, October 2013, p.19) that use of an incision to admit the needle or to anchor the lead is inherent to percutaneous placement and does not alter use of code 63650.
  8. When implantation of two leads is coded and billed, ie. 63650 plus 63650-59, the entire encounter continues to map to the APCs shown. Because these are C-APCs and no complexity adjustment applies, there is no additional payment for the second lead.
  9. NCCI policy does not allow removal of the existing generator to be coded separately. When an existing generator is removed and replaced by a new generator, only the generator replacement code 63685 may be assigned. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  10. When generator implantation is coded and billed together with lead implantation, for example 63685 plus 63650, the entire encounter continues to map to the APC for generator implantation. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the lead.
  11. The AMA has published that the work of removing a temporary trial lead is inherent to the original percutaneous placement code 63650 and is not coded separately. Code 63661 cannot be assigned for removal of a temporary trial lead that was placed percutaneously. Further, codes 63661 and 63662 apply to surgical removal of permanent leads. Removal of a permanent lead by simple pull is not coded (CPT Assistant, August 2010, p.8,15; April 2011,p.10-11,15).
  12. The AMA has published that replacement codes 63663 and 63664 are assigned when a permanent lead is replaced by another permanent lead of the same type via the same approach at the same spinal level. The work of removing the existing permanent lead is included and is not coded separately (CPT Assistant, August 2010, p.8,15; April 2011,p.10-11,15).
  13. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, insertion code 63655 is assigned with removal code 63661 (CPT Assistant, April 2011,p.11,15). NCCI edits allow this combination without use of a modifier.
  14. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature.
  15. According to CPT manual instructions, append modifier -52 for reduced services to code 95972 if complex programming lasts less than 31 minutes. For hospital outpatient reporting, modifier -52 is used to indicate partial reduction of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 20.6.4.A. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Accessed November 11, 2014.
  1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates Final Rule, 79 Fed. Reg. 49853-50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 23, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates Final Rule, 79 Fed. Reg. 49853-50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2013. Accessed September 23, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown
  4. Although neurostimulators are nervous system devices, implantation procedures are assigned to Mental Disorder MS-DRGs when neurostimulators are implanted for OCD.
  5. 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Final Rule, 79 Fed. Reg. 49853—50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 29, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. 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 whole system implantation in which both the leads 04.92 and the generator 86.95 are coded, MS-DRG 042 cannot be assigned. Instead, MS-DRG 041 is automatically assigned for a whole system implantation regardless of whether a CC is present or not. If an MCC is also present with a whole system implantation, MS-DRG 040 is assigned. For other Enterra procedures, such as lead only implantation 04.92 or lead removal 04.93, 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2015 Rates, Final Rule 79 Fed. Reg. 49853– 50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 29, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2015 Rates, Final Rule 79 Fed. Reg. 49853– 50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 29, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. 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 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2015 Rates, Final Rule 79 Fed. Reg. 49853– 50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 29, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare and Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2015 Rates, Final Rule 79 Fed. Reg. 49853– 50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 29, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. There are three MS-DRGs for spinal procedures with a nervous system principal diagnosis (DRGs 028, 029, and 030); the difference is whether secondary diagnoses are designated as MCCs or CCs. However, for a whole system 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 whole system implantation regardless of whether a CC is present or not. If an MCC is also present with a whole 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 MS-DRGs 028, 029, and 030 is available.
  5. There are three MS-DRGs for back and neck procedures with a musculoskeletal system principal diagnosis (DRGs 518, 519 and 520); the difference is whether secondary diagnoses are designated as MCCs or CCs. However, for a whole system neurostimulator implantation in which both the leads 03.93 and the generator 86.94–86.98 are coded, MS-DRG 518 is automatically assigned regardless of whether an MCC is present. For other spinal procedures, such as lead only implantation 03.93, the full range of MS-DRGs 518, 519 and 520 is available.
  6. The ICD-9-CM codes for generator implantation are not specific to spinal neurostimulation so the MS-DRGs for Other Nervous System Procedures are assigned.
  7. 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.
  8. 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 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  3. The Payment Indicator shows how a code is handled for payment purposes. 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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  8. These instructions for billing bilateral neurostimulators are for Medicare claims. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14, Section 40.5. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf. Updated May 23, 2008 . Accessed November 11, 2014. For billing bilateral neurostimulators to non-Medicare payers, contact the payer for instructions.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  3. The Payment Indicator shows how a code is handled for payment purposes. 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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  8. These instructions for billing bilateral neurostimulators are for Medicare claims. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14, Section 40.5. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf. Updated May 23, 2008. Accessed November 11, 2014. For billing bilateral neurostimulators to non-Medicare payers, contact the payer for instructions.
  1. 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 2015” 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 (Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14—Ambulatory Surgical Centers, section 10.2. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf. Accessed November 11, 2014.). Medicare’s list of covered surgical procedures is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html
  2. CPT copyright 2014 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  4. 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.
  5. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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.
  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. Procedures subject to discounting are marked “Y.” However, procedures marked “N” are not subject to 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. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. National Correct Coding Initiative (NCCI) policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  9. According to NCCI policy and AMA coding precedent, an EGD should not be coded separately when performed by the physician to assess the surgical field and anatomic landmarks or to confirm successful lead placement during the same operative episode as lead implantation. However, an EGD performed for diagnostic purposes at a separate encounter from lead implantation may be coded.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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, payment based on hospital outpatient rate; 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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 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. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  9. 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.”
  10. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  11. Code J2274 is packaged and not separately payable. However, J2278 is designated as an “ASC covered ancillary service integral to covered surgical procedures for Calendar Year 2015” and it generates separate payment. For 2015, the payment amount is based on ASP plus 6%. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66891, 66933. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014). ASP values are publicly available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis.
  12. Use the Refill/Analysis/Reprogramming codes only for follow-up services. NCCI edits do not allow these codes to be assigned at the time of pump implantation.
  13. 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 or equivalent.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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, payment based on hospital outpatient rate; 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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 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. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  9. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  10. Although most drugs are packaged and not separately payable, both code J0475 and code J0476 are designated as “ASC covered ancillary services integral to covered surgical procedures for Calendar Year 2015” 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.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. For 2015, the payment amount is based on ASP plus 6% (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66891, 66933. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  11. Use the Refill/Analysis/Reprogramming 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 ASC ancillary staff, eg. nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by a physician or equivalent.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Z3 = radiology service, paid separately when provided integral to an ASC surgical procedure.
  4. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 procedures and 50% of the rate for the second and all subsequent procedures. Procedures subject to discounting 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. The FDA has approved placing two temporary test stimulation leads during a single bilateral procedure. As defined and as published by the AMA (CPT Assistant, December 2008, p.8-9), 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” (Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14—Ambulatory Surgery Centers, section 40.5). Medicare’s Medically Unlikely Edits allow 1 unit for code 64561 on the same date of service. Because ASCs cannot submit the bilateral modifier, CMS doubles the MUE to allow 2 units specifically for ASCs. (Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf. Released August 15, 2014. Accessed November 17, 2014.)
  8. As defined and as published by the AMA (CPT Assistant, December 2008, p.8-9), code 64581 represents a single lead, and when more than one lead is placed, each is coded separately. ASCs can identify distinct leads by reporting code 64581 on two separate lines and appending modifier –59 to the second lead insertion code, or by reporting 64581 on a single line with units of “2”. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 64581 on the same date of service.
  9. Because the definition of code 64561 includes image guidance, use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. (See also CPT Assistant, September 2014, p.5.) Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581.
  10. For lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  11. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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. As published by the AMA (CPT Assistant, June 1998, p.4), these codes represent a single lead. When more than one lead is placed, each is coded separately. 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” (Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14—Ambulatory Surgery Centers, section 40.5). Some payers may recognize that each code represents a distinct lead when modifier –59 is appended to the additional codes. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 on the same date of service, but only 1 unit for code 63655. Denials for units in excess of the MUE values may be appealed.
  8. The AMA has published (CPT Assistant, October 2013, p.19) that use of an incision to admit the needle or to anchor the lead is inherent to percutaneous placement and does not alter use of code 63650.
  9. National Correct Coding Initiative (NCCI policy does not allow removal of the existing generator to be coded separately. When an existing generator is removed and replaced by a new generator, only the generator replacement code 63685 may be assigned. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  10. 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. Code 63661 cannot be assigned for removal of a temporary trial lead that was placed percutaneously. Further, codes 63661 and 63662 apply to surgical removal of permanent leads. Removal of a permanent lead by simple pull is not coded (CPT Assistant, August 2010, p.8,15; April 2011,p.10-11,15).
  11. The AMA has published that replacement codes 63663 and 63664 are assigned when a permanent lead is replaced by another permanent lead of the same type via the same approach at the same spinal level. The work of removing the 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 (CPT Assistant, April 2011,p.11,15). NCCI edits allow this combination without use of a modifier.

Physician Office

CPT® Procedure Codes

Physicians use CPT codes for all services. Under Medicare's Resource-Based Relative Value Scale (RBRVS) methodology for physician payment, each CPT code is assigned a point value, the relative value unit (RVU), which is then converted to a flat payment amount.

References
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed. Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014. (The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.)
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Accessed November 13, 2014.
  6. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate encounter, in the physician’s office, and/or on a different date prior to the lead implantation. CPT Assistant, October 2010, p.9.
  7. Pre-operative CT and MRI imaging may be separately coded when they represent full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately. Note that although CPT code 61781 exists for computer-assisted intradural surgical navigation, CPT manual instructions and National Correct Coding Initiative (NCCI) edits do not allow this to be coded separately with lead implantation codes 61863 and 61867.
  8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure.
  9. This assumes the service is occurring in the hospital facility, because the primary lead procedure must be performed in a facility. So the physician is providing the professional interpretation only (-26) and only facility RVUs and payments are displayed.
  10. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed, or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  11. In a lead replacement, NCCI edits do not permit removal of an existing lead to be coded separately with placement of a new lead.
  12. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  13. As defined, microelectrode recording is included in codes 61867 - 61868. CPT manual instructions and NCCI edits do not allow 95961 - 95962 to be coded separately with lead implantation when microelectrode recording is performed by the operating surgeon. However, the AMA has published that when another physician (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. CPT Changes 2004: An Insider’s View, p.93.
  14. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature (e.g., rigidity, dyskinesia, tremor).
  15. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15.
  16. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed. Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014. (The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.)
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Accessed November 13, 2014
  6. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate encounter, in the physician’s office, and/or on a different date prior to the lead implantation. CPT Assistant, October 2010, p.9.
  7. Pre-operative CT and MRI imaging may be separately codable when it represents full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately. Note that although CPT code 61781 exists for computer-assisted intradural surgical navigation, CPT manual instructions and National Correct Coding Initiative (NCCI) edits do not allow this to be coded separately with lead implantation codes 61863 and 61867.
  8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure.
  9. This assumes the service is occurring in the hospital facility, because the primary lead procedure must be performed in a facility. So the physician is providing the professional interpretation only (-26) and only facility RVUs and payments are displayed.
  10. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed, or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  11. In a lead replacement, NCCI edits do not permit removal of an existing lead to be coded separately with placement of a new lead.
  12. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  13. As defined, microelectrode recording is included in codes 61867 - 61868. CPT manual instructions and NCCI edits do not allow 95961 - 95962 to be coded separately with lead implantation when microelectrode recording is performed by the operating surgeon. However, the AMA has published that when another physician (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. CPT Changes 2004: An Insider’s View, p.93
    • According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature (e.g., rigidity, dyskinesia, tremor).
    • The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15.
    • According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014. (The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.)
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Published November 13, 2014. Accessed November 17, 2014.
  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. Contractor-priced codes require the payer to determine whether the global concept applies and to establish the postoperative period at time of pricing.
  7. For lead replacement, National Correct Coding Initiative (NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  8. Although two leads are implanted, these codes are assigned just once. The published vignettes for lead implantation codes 43647 and 43881 include two leads, and Medicare’s Medically Unlike Edits allow just 1 unit for code 43647 and just 1 unit for code 43881.
  9. Although payable to the physician as determined by the contractor, Medicare restricts corresponding payment to the facility by site of service. Medicare allows laparoscopic lead implantation 43647 and revision 43648 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.
  10. For Medicare, this is a contractor-priced code. Contractors establish the RVUs and the payment amount, usually on an individual basis after review of the procedure report.
  11. RVUs exist for this code in the office setting. However, they are not displayed because generator implantation and replacement customarily take place in the facility setting.
  12. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  13. According to NCCI policy and AMA coding precedent, an EGD should not be coded separately when performed by the physician to assess the surgical field and anatomic landmarks or to confirm successful lead placement during the same operative episode as lead implantation. In both scenarios, however, an EGD performed by a different physician or performed for distinct diagnostic purposes may be coded separately.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014. (The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.)
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. “N/A” 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Published November 13, 2014. Accessed November 17, 2014.
  6. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited because codes 62311 and 62319 are already valued to include fluoroscopic guidance. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  8. 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.
  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, 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. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  11. Payer interpretations on coding, billing and payment for the drug may vary. For coding and billing, some contractors instruct that modifier -KD, defined “drug or biological infused through DME”, be appended to the drug code when the drug is infused via an implanted pump. However, other contractors instruct the modifier -KD is reserved for external pumps and should not be appended for drugs infused via an implanted pump. For payment, some contractors make payment for the drug at 95% of AWP and others make payment at ASP + 6%. (ASP and AWP values are available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html and are updated quarterly.) Providers should check with the local Medicare contractor or other payers for their specific coding, billing and payment instructions.
  12. 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.
  13. Use the Refill/Analysis/Reprogramming 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 assigned 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 assigned when the pump is both interrogated and reprogrammed.
  15. Code 62369 is assigned when the pump is interrogated, reprogrammed and refilled by ancillary staff, eg. nurse under physician supervision in the office. Although RVUs exist for code 62369 in the facility setting, they are not displayed because the service is typically provided by facility staff, eg. hospital nurse. As defined, code 62370 is used when the pump is interrogated, reprogrammed, and refilled by a physician or “other qualified health care professional”. The AMA defines “other qualified health care professional” as an individual who performs professional services within their scope of practice and is able to bill their services independently, eg. nurse practitioner.
  16. Codes 95990 and 95991 are used only when the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published (CPT Assistant, July 2006, p.2) that programmable pumps require reprogramming at the time of refilling. For this reason, codes 95990 and 95991 are generally used for refilling and maintenance of non-programmable pumps.
  17. The AMA has published material (CPT Assistant, September 2008, p.10) confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  18. RVUs exist for this code in the office setting. However, they are not displayed because the professional component –26 is customarily provided in the facility setting.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. “N/A” 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Published November 13, 2014. Accessed November 17, 2014.
  6. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited because codes 62311 and 62319 are already valued to include fluoroscopic guidance. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  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, treatment of complications unless they require a return visit to the operating room, and minor post– operative services such as dressing changes and suture removal.
  9. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  10. Payer interpretations on coding, billing and payment for the drug may vary. For coding and billing, some contractors instruct that modifier -KD, defined “drug or biological infused through DME”, be appended to the drug code when the drug is infused via an implanted pump. However, other contractors instruct the modifier -KD is reserved for external pumps and should not be appended for drugs infused via an implanted pump. For payment, some contractors make payment for the drug at 95% of AWP and others make payment at ASP + 6%. (ASP and AWP values are available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html and are updated quarterly.) Providers should check with the local Medicare contractor or other payers for their specific coding, billing and payment instructions.
  11. Use the Refill/Analysis/Reprogramming 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 assigned 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 assigned when the pump is both interrogated and reprogrammed.
  13. Code 62369 is assigned when the pump is interrogated, reprogrammed and refilled by ancillary staff, eg. nurse under physician supervision in the office. Although RVUs exist for code 62369 in the facility setting, they are not displayed because the service is typically provided by facility staff, eg. hospital nurse. As defined, code 62370 is used when the pump is interrogated, reprogrammed, and refilled by a physician or “other qualified health care professional”. The AMA defines “other qualified health care professional” as an individual who performs professional services within their scope of practice and is able to bill their services independently, eg. nurse practitioner.
  14. Codes 95990 and 95991 are used only when the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published (CPT Assistant, July 2006, p.2) that programmable pumps require reprogramming at the time of refilling. For this reason, codes 95990 and 95991 are generally used for refilling and maintenance of non-programmable pumps.
  15. The AMA has published material (CPT Assistant, September 2008, p.10) confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  16. RVUs exist for this code in the office setting. However, they are not displayed because the professional component –26 is customarily provided in the facility setting.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule 79 Fed. Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 17, 2014. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Published November 13, 2014. Accessed November 17, 2014.
  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 (CPT Assistant, December 2008, p.8-9), code 64561 represents a single lead, and when more than one lead is placed, each is coded separately. Medicare does permit the use of bilateral modifier -50 with code 64561. Medicare’s Medically Unlikely Edits allow 1 unit for code 64561 on the same date of service. To show placement of two test leads, submit 64561-50 with 1 unit. (Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf. Released August 15, 2014. Accessed November 17, 2014.).
  8. National Correct Coding Initiative (NCCI) policy and edits do not allow HCPCS II test lead code A4290 to be submitted with procedure code 64561, because code 64561 is already valued to include the test lead.
  9. As defined and as published by the AMA (CPT Assistant, December 2008, p.8-9), code 64581 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 or –L T/ –RT with code 64581. Some payers recognize that each code represents a distinct lead when modifier –51 or modifier –59 is appended to the additional code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 64581 on the same date of service.
  10. Because the definition of code 64561 includes image guidance, use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. (See also CPT Assistant, September 2014, p.5.) Similarly, NCCI edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581.
  11. RVUs exist for this code in the office setting. However, they are not displayed because the professional component –26 is customarily provided in the facility setting.
  12. For lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  13. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  14. RVUs exist for this code in the office setting. However, they are not displayed because generator implantation and replacement customarily take place in the facility setting.
  15. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature.
  16. According to CPT manual instructions, append modifier -52 for reduced services to code 95972 if complex programming lasts less than 31 minutes.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule 79 Fed. Reg. 67547-68092. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 17, 2014. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.
  3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Centers for Medicare & Medicaid Services PFS Relative Value File (January Release). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. Accessed January 5, 2015. 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. Centers for Medicare & Medicaid Services. Details for Title: CMS-1612-FC. CY 2015 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. Published November 13, 2104. Accessed November 17, 2014.
  6. As defined and as published by the AMA (CPT Assistant, June 1998, p.4), these codes represent a single lead. When more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 or –L T/ –RT on these codes. Some payers recognize that each code represents a distinct lead when modifier –51 or modifier –59 is appended to the additional codes. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 on the same date of service, but only 1 unit for code 63655. Denials for units in excess of the MUE values may be appealed.
  7. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 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.
  8. The published vignettes for codes 63650 and 63655 include fluoroscopy and, according to guidelines published by the American Association of Neurological Surgeons (AANS Guide to Coding, 2012 Edition, p.66), its use is inherent to lead implantation and should not be coded separately. In addition, National Correct Coding Initiative (NCCI) edits prohibit coding fluoroscopy separately with 63650 and 63655.
  9. The Physician Office RVUs for code 63650 are valued to include payment for the lead and other practice expenses associated with office-based trials. HCPCS code L8680 should not be reported separately for the lead in conjunction with office-based trials.
  10. The AMA has published (CPT Assistant, October 2013, p.19) that use of an incision to admit the needle or to anchor the lead is inherent to percutaneous placement and does not alter use of code 63650.
  11. When an existing generator is removed and replaced by a new generator, only the generator replacement code 63685 may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  12. The AMA has published that the work of removing a temporary trial lead is inherent to the original percutaneous placement code 63650 and is not coded separately. Code 63661 cannot be assigned for removal of a temporary trial lead that was placed percutaneously. Further, codes 63661 and 63662 apply to surgical removal of permanent leads . Removal of a permanent lead by simple pull is not coded (CPT Assistant, August 2010, p.8,15; April 2011,p.10-11,15).
  13. The AMA has published that replacement codes 63663 and 63664 are assigned when a permanent lead is replaced by another permanent lead of the same type via the same approach at the same spinal level. The work of removing the existing permanent lead is included and is not coded separately (CPT Assistant, August 2010, p.8,15; April 2011,p.10-11,15).
  14. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, insertion code 63655 is assigned with removal code 63661 (CPT Assistant, April 2011,p.11,15). NCCI edits allow this combination without use of a modifier.
  15. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature.
  16. According to CPT manual instructions

 

Hospital Outpatient

CPT® Procedure Codes

Hospitals use CPT codes for outpatient services. Under Medicare’s APC methodology for hospital outpatient payment, each CPT code is assigned to one of approximately 765 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 encounter, depending on the number of procedures coded and whether any of the procedure codes map to a Comprehensive APC.

Effective January 1, 2015, CMS has designated 25 APCs as Comprehensive APCs (C‐APCs). Each CPT procedure code assigned to one of these C‐APCs is considered a primary service, and all other procedures and services coded on the bill are considered adjunctive to delivery of the primary service. This results in a single APC payment and a single beneficiary copayment for the entire outpatient encounter, based solely on the primary service. Separate payment is not made for the other adjunctive services. Instead, the payment level for the C‐APC is calculated to include the costs of the other adjunctive services, which are packaged into the payment for the primary service. C‐APCs are identified by status indicator J1.

The National Averages are calculated per the footnotes included and do not take into effect Medicare payment reductions resulting from sequestration associated with the Budget Control Act of 2011. Sequestration reductions went into effect on April 1, 2013.

References
  1. . CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure; J1 = paid under a comprehensive APC, single payment based on primary service without separate payment for other adjunctive services. See note 7 for status indicator Q3.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate outpatient encounter on a different date prior to the inpatient lead implantation. CPT Assistant, October 2010, p.9. Further, under Medicare’s current “3-day payment window” policy, all non-diagnostic services performed during the three calendar days preceding the admission “are deemed related to the admission and thus must be billed … with the inpatient stay”. Medicare Claims Processing Manual, Chapter 4, section 10.12. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 10.12. http://ww.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated February 7, 2014. Accessed November 11, 2014. Note that hospital charges related to the fiducials may be rolled into the inpatient stay.
  6. Pre-operative CT and MRI imaging may be coded separately when they represent full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately.
  7. More broadly, these codes have status indicator Q3. For CT and MRI, status indicator Q3 shows that the service may be part of a composite APC if billed with other similar imaging services. However, within the context of services related to Medtronic DBS Therapy, the codes will generally be paid separately under the APCs, status indicators, and rates shown.
  8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure. However, they are packaged into APC payment for the base imaging and are not separately payable.
  9. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  10. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature, (e.g., rigidity, dyskinesia, tremor).
  11. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15.
  12. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes. For hospital outpatient reporting, modifier -52 is used to indicate partial reduction of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 20.6.4.A. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated January 13, 2012. Accessed November 11, 2014.
  1. CPT Copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure; J1 = paid under a comprehensive APC, single payment based on primary service without separate payment for other adjunctive services. See note 7 for status indicator Q3.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate outpatient encounter on a different date prior to the inpatient lead implantation. CPT Assistant, October 2010, p.9. Further, under Medicare’s current “3-day payment window” policy, all non-diagnostic services performed during the three calendar days preceding the admission “are deemed related to the admission and thus must be billed … with the inpatient stay”. Medicare Claims Processing Manual, Chapter 4, section 10.12. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 10.12. http://ww.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated February 7, 2014. Accessed November 11, 2014. Note that hospital charges related to the fiducials may be rolled into the inpatient stay.
  6. Pre-operative CT and MRI imaging may be coded separately when they represent full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately.
  7. More broadly, these codes have status indicator Q3. For CT and MRI, status indicator Q3 shows that the service may be part of a composite APC if billed with other similar imaging services. However, within the context of services related to Medtronic DBS Therapy, the codes will generally be paid separately under the APCs, status indicators, and rates shown.
  8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure. However, they are packaged into APC payment for the base imaging and are not separately payable.
  9. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  10. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature, (e.g., rigidity, dyskinesia, tremor).
  11. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15.
  12. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes. For hospital outpatient reporting, modifier -52 is used to indicate partial reduction of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 20.6.4.A. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated January 13, 2012. Accessed November 11, 2014.
  1. CPT copyright 2014 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure, Q2 = T packaged codes, not paid separately when billed with a T procedure; .J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 lead replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  7. Although two leads are implanted, code 43647 is assigned just once. The code’s published vignette includes two leads, and Medicare’s Medically Unlike Edits allow just 1 unit for code 43647.
  8. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  9. When generator implantation is coded and billed together with lead implantation, for example 64590 plus 43647, the entire encounter continues to map to the APC for generator implantation. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the lead.
  10. According to NCCI policy and AMA coding precedent, an EGD should not be coded separately when performed by the physician to assess the surgical field and anatomic landmarks or to confirm successful lead placement during the same operative episode as lead implantation. In both scenarios, however, an EGD performed for distinct diagnostic purposes may be coded separately.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use..
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; N = packaged service, no separate payment; J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services; K = non-pass-through drugs, paid under separate APC unless submitted with J1. See notes 10 and 17 for status indicator Q2.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  7. 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.”.
  8. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  9. When pump implantation is coded and billed together with catheter implantation, ie, 62362 plus 62350, the entire encounter continues to map to the APC for pump implantation. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the catheter.
  10. Status Q2 indicates that device removal codes 62355 and 62365 are conditionally packaged. When submitted with another code with status “T”, such as the catheter implantation code 62350 or catheter dye study code 61070, the device removal codes are packaged into the primary service and are not separately payable. However, a device removal code is separately payable when it is the only procedure performed. When both device removal codes 62355 and 62365 are performed together, with no other procedures, then higher-weighted code 62365 is paid and lower-weighted code 62355 is packaged and not separately payable.
  11. Code J2274 is packaged and not separately payable. However, except in one specific scenario (see note 12), code J2278 is designated as a “specified covered outpatient drug.” It is assigned to an APC and generates separate payment. ASP values are publicly available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. For 2015, the payment amount is based on ASP plus 6%. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66891. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  12. Code J2278 is not paid separately when the pump is filled with Ziconotide during the same encounter as when the pump is implanted. Because pump implantation code 62362 maps to a C-APC and is status J1, there is no separate payment for adjunctive services such as higher cost drugs (see also Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66800, 66808. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.)
  13. Use the Refill/Analysis/Reprogramming 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 hospital ancillary staff, eg nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician or equivalent.
  15. Code 95990 and 95991 are used only when the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published (CPT Assistant, July 2006, p.2) that programmable pumps require reprogramming at the time of refilling. For this reason, codes 95990 and 95991 are generally used for refilling and maintenance of non-programmable pumps.
  16. The AMA has published material (CPT Assistant, September 2008, p.10) confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  17. Status Q2 indicates that code 75809 is conditionally packaged. Although separately payable in certain unusual circumstances, it 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.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services; K = non-pass-through drugs, paid under separate APC unless submitted with J1. See notes 12 and 19 for status indicator Q2. See note 7 for status indicator A.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  7. The physician performs the injection itself. The hospital-employed physical therapist performs the baseline evaluation and periodic assessments over the course of 6 to 8 hours to gauge the effectiveness of the ITB therapy, outside of standard evaluation for any complications and routine recovery from the injection. Under APCs, physical therapy services billed by a hospital are status A. A = services furnished to a hospital outpatient that are paid separately under a different fee schedule. Physical therapy services billed by a hospital are paid to the hospital using fees from the Physician Fee Schedule.
  8. Use of code 97001 for the ITB screening test assumes that prior evaluation had not been performed. The PT must document the impairment as well as all conditions and complexities that may impact the treatment, the current functional status, objective measurements, clinical judgments, a determination of whether or not the therapy could be useful, and a prognosis for benefit.
  9. Use of code 97750 for the periodic assessments reflects additional objective documentation of a patient’s condition or status, usually performed every two hours after the injection. Observational assessment may be included but hands-on measurement is required. These type of tests include isokinetic testing, functional capacity evaluation, and gait and balance assessments, including the Ashworth scale. A distinct report is required, documenting the specific test performed, the time spent, and the test results as well as how results could impact treatment planning.
  10. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  11. When pump implantation is coded and billed together with catheter implantation, ie, 62362 plus 62350, the entire encounter continues to map to the APC for pump implantation. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the catheter.
  12. Status Q2 indicates that device removal codes 62355 and 62365 are conditionally packaged. When submitted with another code with status “T”, such as the catheter implantation code 62350 or catheter dye study code 61070, the device removal codes are packaged into the primary service and are not separately payable. However, a device removal code is separately payable when it is the only procedure performed. When both device removal codes 62355 and 62365 are performed together, with no other procedures, then higher-weighted code 62365 is paid and lower-weighted code 62355 is packaged and not separately payable.
  13. Except in one specific scenario (see note 14), J0475 and J0476 are both designated as a “specified covered outpatient drug.” Each is assigned to an APC and generates separate payment. ASP values are publicly available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. For 2015, the payment amount is based on ASP plus 6% (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66891. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  14. Code J0475 is not paid separately when the pump is filled with baclofen during the same encounter as when the pump is implanted. Because pump implantation code 62362 maps to a C-APC and is status J1, there is no separate payment for adjunctive services such as higher cost drugs (see also Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66800, 66808. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.)
  15. Use the Refill/Analysis/Reprogramming codes only for follow-up services. NCCI edits do not allow these codes to be assigned at the time of pump implantation.
  16. 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 a physician or equivalent
  17. Codes 95990 and 95991 are used only when the pump is interrogated and refilled without being reprogrammed. In the context of a refill, the AMA has published (CPT Assistant, July 2006, p.2) that programmable pumps require reprogramming at the time of refilling. For this reason, codes 95990 and 95991 are generally used for refilling and maintenance of non-programmable pumps.
  18. The AMA has published material (CPT Assistant, September 2008, p.10) confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  19. Status Q2 indicates that code 75809 is conditionally packaged. Although separately payable in certain unusual circumstances, it 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.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure, Q2 = T packaged codes, not paid separately when billed with a T procedure; .J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 (CPT Assistant, December 2008, p.8-9), code 64561 represents a single lead, and when more than one lead is placed, each is coded separately. Medicare does permit the use of bilateral modifier -50 with code 64561. Medicare’s Medically Unlikely Edits allow 1 unit for code 64561 on the same date of service. To show placement of two test leads, submit 64561-50 with 1 unit. (Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf. Released August 15, 2014. Accessed November 17, 2014.)
  6. When bilateral implantation of two percutaneous test leads is coded and billed, ie. 64561-50, the entire encounter continues to map to APC 0061. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the second lead.
  7. As defined and as published by the AMA (CPT Assistant, December 2008, p.8-9), code 64581 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 or –L T/ –RT with code 64581. Payers recognize that each code represents a distinct lead when modifier –59 is appended to the additional code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 64581 on the same date of service.
  8. Because the definition of code 64561 includes image guidance, use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. (See also CPT Assistant, September 2014, p.5.) Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581.
  9. For lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  10. When generator implantation is coded and billed together with lead implantation, ie. 64590 plus 64581, the entire encounter continues to map to the APC for generator implantation. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the lead.
  11. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  12. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature.
  13. According to CPT manual instructions, append modifier -52 for reduced services to code 95972 if complex programming lasts less than 31 minutes. For hospital outpatient reporting, modifier -52 is used to indicate partial reduction of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 20.6.4.A. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Accessed November 11, 2014.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66769-67034. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure ; J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2015 is $74.144. The conversion factor of $74.144 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66825-66826. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 defined and as published by the AMA (CPT Assistant, June 1998, p.4), these codes represent a single lead, and when more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 or –L T/ –RT on these codes. Some payers recognize that each code represents a distinct lead when modifier –59 is appended to the additional codes. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 on the same date of service, but only 1 unit for code 63655. Denials for units in excess of the MUE values may be appealed.
  6. The published vignettes for codes 63650 and 63655 include fluoroscopy and, according to guidelines published by the American Association of Neurological Surgeons (AANS Guide to Coding, 2012 Edition, p.66), its use is inherent to lead implantation and should not be coded separately. In addition, National Correct Coding Initiative (NCCI) edits prohibit coding fluoroscopy separately with 63650 and 63655.
  7. The AMA has published (CPT Assistant, October 2013, p.19) that use of an incision to admit the needle or to anchor the lead is inherent to percutaneous placement and does not alter use of code 63650.
  8. When implantation of two leads is coded and billed, ie. 63650 plus 63650-59, the entire encounter continues to map to the APCs shown. Because these are C-APCs and no complexity adjustment applies, there is no additional payment for the second lead.
  9. NCCI policy does not allow removal of the existing generator to be coded separately. When an existing generator is removed and replaced by a new generator, only the generator replacement code 63685 may be assigned. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  10. When generator implantation is coded and billed together with lead implantation, for example 63685 plus 63650, the entire encounter continues to map to the APC for generator implantation. Because this is a C-APC and no complexity adjustment applies, there is no additional payment for the lead.
  11. The AMA has published that the work of removing a temporary trial lead is inherent to the original percutaneous placement code 63650 and is not coded separately. Code 63661 cannot be assigned for removal of a temporary trial lead that was placed percutaneously. Further, codes 63661 and 63662 apply to surgical removal of permanent leads. Removal of a permanent lead by simple pull is not coded (CPT Assistant, August 2010, p.8,15; April 2011,p.10-11,15).
  12. The AMA has published that replacement codes 63663 and 63664 are assigned when a permanent lead is replaced by another permanent lead of the same type via the same approach at the same spinal level. The work of removing the existing permanent lead is included and is not coded separately (CPT Assistant, August 2010, p.8,15; April 2011,p.10-11,15).
  13. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, insertion code 63655 is assigned with removal code 63661 (CPT Assistant, April 2011,p.11,15). NCCI edits allow this combination without use of a modifier.
  14. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature.
  15. According to CPT manual instructions, append modifier -52 for reduced services to code 95972 if complex programming lasts less than 31 minutes. For hospital outpatient reporting, modifier -52 is used to indicate partial reduction of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 20.6.4.A. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Accessed November 11, 2014.

 

Hospital Inpatient

MS-DRG Assignments

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.

References
  1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates Final Rule, 79 Fed. Reg. 49853-50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 23, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates Final Rule, 79 Fed. Reg. 49853-50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2013. Accessed September 23, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. Although neurostimulators are nervous system devices, implantation procedures are assigned to Mental Disorder MS-DRGs when neurostimulators are implanted for OCD.
  5. 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Final Rule, 79 Fed. Reg. 49853—50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 29, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. 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 whole system implantation in which both the leads 04.92 and the generator 86.95 are coded, MS-DRG 042 cannot be assigned. Instead, MS-DRG 041 is automatically assigned for a whole system implantation regardless of whether a CC is present or not. If an MCC is also present with a whole system implantation, MS-DRG 040 is assigned. For other Enterra procedures, such as lead only implantation 04.92 or lead removal 04.93, 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2015 Rates, Final Rule 79 Fed. Reg. 49853– 50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 29, 2014
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2015 Rates, Final Rule 79 Fed. Reg. 49853– 50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 29, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. 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 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2015 Rates, Final Rule 79 Fed. Reg. 49853– 50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 29, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare and Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. 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. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2015 Rates, Final Rule 79 Fed. Reg. 49853– 50536. http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf. Published August 22, 2014. Accessed September 29, 2014.
  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 ($5,437.85) plus the capital standard amount ($434.97). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2015 Rates; Correction, 79 Fed. Reg. 59683-59684. Tables 1A-1D. http://www.gpo.gov/fdsys/pkg/FR-2014-10-03/pdf/2014-23630.pdf. Published October 3, 2014. Accessed November 11, 2014. 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 a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  4. There are three MS-DRGs for spinal procedures with a nervous system principal diagnosis (DRGs 028, 029, and 030); the difference is whether secondary diagnoses are designated as MCCs or CCs. However, for a whole system 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 whole system implantation regardless of whether a CC is present or not. If an MCC is also present with a whole 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 MS-DRGs 028, 029, and 030 is available.
  5. There are three MS-DRGs for back and neck procedures with a musculoskeletal system principal diagnosis (DRGs 518, 519 and 520); the difference is whether secondary diagnoses are designated as MCCs or CCs. However, for a whole system neurostimulator implantation in which both the leads 03.93 and the generator 86.94–86.98 are coded, MS-DRG 518 is automatically assigned regardless of whether an MCC is present. For other spinal procedures, such as lead only implantation 03.93, the full range of MS-DRGs 518, 519 and 520 is available.
  6. The ICD-9-CM codes for generator implantation are not specific to spinal neurostimulation so the MS-DRGs for Other Nervous System Procedures are assigned.
  7. 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.
  8. 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.

 

Ambulatory Surgery Center

CPT® Procedure Codes

ASCs use CPT codes for their services. Medicare payment for procedures performed in an ambulatory surgery center is based on Medicare's ambulatory 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.

References
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  3. The Payment Indicator shows how a code is handled for payment purposes. 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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  8. These instructions for billing bilateral neurostimulators are for Medicare claims. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14, Section 40.5. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf. Updated May 23, 2008. Accessed November 11, 2014. For billing bilateral neurostimulators to non-Medicare payers, contact the payer for instructions.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  3. The Payment Indicator shows how a code is handled for payment purposes. 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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed. Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  8. These instructions for billing bilateral neurostimulators are for Medicare claims. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14, Section 40.5. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf. Updated May 23, 2008. Accessed November 11, 2014. For billing bilateral neurostimulators to non-Medicare payers, 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 2015” 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 (Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14—Ambulatory Surgical Centers, section 10.2. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf. Accessed November 11, 2014.). Medicare’s list of covered surgical procedures is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html

  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 procedures and 50% of the rate for the second and all subsequent procedures. Procedures subject to discounting are marked “Y.” However, procedures marked “N” are not subject to 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. National Correct Coding Initiative (NCCI) policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  8. According to NCCI policy and AMA coding precedent, an EGD should not be coded separately when performed by the physician to assess the surgical field and anatomic landmarks or to confirm successful lead placement during the same operative episode as lead implantation. However, an EGD performed for diagnostic purposes at a separate encounter from lead implantation may be coded.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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, payment based on hospital outpatient rate; 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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 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. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  9. 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.”
  10. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  11. Code J2274 is packaged and not separately payable. However, J2278 is designated as an “ASC covered ancillary service integral to covered surgical procedures for Calendar Year 2015” and it generates separate payment. For 2015, the payment amount is based on ASP plus 6%. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66891, 66933. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014). ASP values are publicly available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis.
  12. Use the Refill/Analysis/Reprogramming codes only for follow-up services. NCCI edits do not allow these codes to be assigned at the time of pump implantation.
  13. 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 or equivalent.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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, payment based on hospital outpatient rate; 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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 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. According to CPT manual instructions, injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used for needle injection or 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. Although CPT manual instructions allow code 77003 for fluoroscopic guidance to be coded separately with injection codes 62311 and 62319, CMS has published that separately coding 77003 is prohibited. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg. 67579. https://federalregister.gov/a/2014-26183. Published November 13, 2014. Accessed November 13, 2014.
  9. For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  10. Although most drugs are packaged and not separately payable, both code J0475 and code J0476 are designated as “ASC covered ancillary services integral to covered surgical procedures for Calendar Year 2015” 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.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. For 2015, the payment amount is based on ASP plus 6% (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg. 66891, 66933. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  11. Use the Refill/Analysis/Reprogramming 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 ASC ancillary staff, eg. nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by a physician or equivalent.
  1. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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; Z3 = radiology service, paid separately when provided integral to an ASC surgical procedure.
  4. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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 procedures and 50% of the rate for the second and all subsequent procedures. Procedures subject to discounting 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. The FDA has approved placing two temporary test stimulation leads during a single bilateral procedure. As defined and as published by the AMA (CPT Assistant, December 2008, p.8-9), 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” (Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14—Ambulatory Surgery Centers, section 40.5). Medicare’s Medically Unlikely Edits allow 1 unit for code 64561 on the same date of service. Because ASCs cannot submit the bilateral modifier, CMS doubles the MUE to allow 2 units specifically for ASCs. (Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf. Released August 15, 2014. Accessed November 17, 2014.)
  8. As defined and as published by the AMA (CPT Assistant, December 2008, p.8-9), code 64581 represents a single lead, and when more than one lead is placed, each is coded separately. ASCs can identify distinct leads by reporting code 64581 on two separate lines and appending modifier –59 to the second lead insertion code, or by reporting 64581 on a single line with units of “2”. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 64581 on the same date of service.
  9. Because the definition of code 64561 includes image guidance, use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. (See also CPT Assistant, September 2014, p.5.) Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581.
  10. For lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  11. When an existing generator is removed and replaced by a new generator, only the generator replacement code may be assigned. NCCI policy does not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new generator. When the same generator is removed and then re-inserted, the “revision” code is used.
  1. CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66915-66940. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014.
  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 2015 ASC conversion factor is $44.071. The conversion factor of $44.071 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg. 66939. https://federalregister.gov/a/2014-26146. Published November 10, 2014. Accessed November 11, 2014. 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. As published by the AMA (CPT Assistant, June 1998, p.4), these codes represent a single lead. When more than one lead is placed, each is coded separately. 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” (Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14—Ambulatory Surgery Centers, section 40.5). Some payers may recognize that each code represents a distinct lead when modifier –59 is appended to the additional codes. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 on the same date of service, but only 1 unit for code 63655. Denials for units in excess of the MUE values may be appealed.
  8. The AMA has published (CPT Assistant, October 2013, p.19) that use of an incision to admit the needle or to anchor the lead is inherent to percutaneous placement and does not alter use of code 63650.
  9. National Correct Coding Initiative (NCCI policy does not allow removal of the existing generator to be coded separately. When an existing generator is removed and replaced by a new generator, only the generator replacement code 63685 may be assigned. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  10. 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. Code 63661 cannot be assigned for removal of a temporary trial lead that was placed percutaneously. Further, codes 63661 and 63662 apply to surgical removal of permanent leads. Removal of a permanent lead by simple pull is not coded (CPT Assistant, August 2010, p.8,15; April 2011,p.10-11,15).
  11. The AMA has published that replacement codes 63663 and 63664 are assigned when a permanent lead is replaced by another permanent lead of the same type via the same approach at the same spinal level. The work of removing the 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 (CPT Assistant, April 2011,p.11,15). NCCI edits allow this combination without use of a modifier.

 

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In early 2014 some specialty provider groups were preparing for the transition to ICD-10-CM. According to a Practice Advantage poll less than 33% were on their way. The groups not yet preparing were not alone. CMS postponed the implementation deadline a year. The new deadline for ICD-10-CM, October 2015, is fast approaching. We’d like to know how many of you are feeling ready for the transition. Please take this quick poll to let others know if you think you’re ready.

 

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