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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 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; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule; 78 Fed. Reg. 74230-74823. https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory. Published December 10, 2013. Accessed January 29, 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013. (Centers for Medicare & Medicaid Services. MLN Connects Provider eNews—Special Edition. http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-27-standalone.pdf. Published December 27, 2013. Accessed January 30, 2014.) Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
  4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.
  5. “N/A” shown in Physician Office setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; (Centers for Medicare & Medicaid Services. Details for Regulation #: CMS-1600-FC. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1600-FC.html. Accessed January 29, 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.
  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. 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.
  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 (eg, rigidity, dyskinesia, tremor).
  15. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators.
  16. According to CPT manual instructions, append modifier -52 to code 95978 if complex programming lasts less than 31 minutes.
  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; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule; 78 Fed. Reg. 74230-74823. https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory. Published December 10, 2013. Accessed January 29, 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013. (Centers for Medicare & Medicaid Services. MLN Connects Provider eNews—Special Edition. http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-27-standalone.pdf. Published December 27, 2013. Accessed January 30, 2014.). 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 Regulation #: CMS-1600-FC. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1600-FC.html. Accessed January 29, 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.
  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.
    • 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.
    • According to CPT manual instructions, append modifier -52 to code 95978 if complex programming lasts less than 31 minutes.
  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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. 74230-74823 (finalized December 10, 2013). 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013 (signed December 26, 2013). 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 setting then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. (finalized December 10, 2013), Addendum A: Explanation of Addendum B and C.
  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 generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  8. 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.
  9. 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.
  10. RVUs exist for this code in the non-facility (office) setting. However, they are not displayed because generator implantation and replacement customarily take place in the facility setting.
  11. According to 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.
  12. 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 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; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule; 78 Fed. Reg. 74230-74823. https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory. Published December 10, 2013. Accessed January 29, 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013. (Centers for Medicare & Medicaid Services. MLN Connects Provider eNews—Special Edition. http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-27-standalone.pdf. Published December 27, 2013. Accessed January 30, 2014.). Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
  4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.
  5. “N/A” shown in Physician Office setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. (finalized December 10, 2013), Addendum A: Explanation of Addendum B and C. “NA” shown in the Facility setting indicates that the service is not paid to the physician in a hospital or ASC, because the service is expected to be performed by employees of the hospital or ASC instead.
  6. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used 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. Check with the payer for specific guidelines on coding a tunneled trial catheter. Options may include 62350, although the code definition specifies “long-term” and the trial is temporary, or 62319 with modifier -22 to indicate that tunneling substantially increases the work.
  8. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  9. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed, or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  10. 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 2014,the payment amount is based on ASP plus 6% per 42CFR 414, Subpart K; Section 112(a) Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) and Medicare Claims Processing Manual (Chapter 17, sections 20.1.2 and 20.1.3, drugs furnished incident to professional service). CMS has published (77 Fed. Reg. 69142, 69147) that when used in refilling an implanted intrathecal pump in the physician office, payment for the drug meets the requirements for “drugs furnished incident to a physician’s services”, rather than drugs administered through covered DME. Nonetheless, check with the local Medicare contractor or other payer s for coding and billing instructions for the KD modifier for “drug or biological infused through DME” as it relates to an implanted pump.
  11. Medicare generally does not pay for supplies separately. However, other payers may make a separate payment depending on the provider contract and their payment methodology.
  12. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. For catheter implantation codes 62350 and 62351, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent, and NCCI edits do not allow 77003 to be coded separately.
  13. 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.
  14. 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.
  15. 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.
  16. Code 62369 is assigned when the pump is interrogated, reprogrammed and refilled by ancillary staff, e.g. 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, e.g. 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, e.g. nurse practitioner.
  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 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 confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  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; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule; 78 Fed. Reg. 74230-74823. https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory. Published December 10, 2013. Accessed January 29, 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013. (Centers for Medicare & Medicaid Services. MLN Connects Provider eNews—Special Edition. http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-27-standalone.pdf. Published December 27, 2013. Accessed January 30, 2014.). Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
  4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.
  5. “N/A” shown in Physician Office setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. (finalized December 10, 2013), Addendum A: Explanation of Addendum B and C. “NA” shown in the Facility setting indicates that the service is not paid to the physician in a hospital or ASC, because the service is expected to be performed by employees of the hospital or ASC instead.
  6. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used 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. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  8. Surgical procedures are subject to a “global period.” The global period defines other physician services which are generally considered part of the surgery package. The services are not separately coded, billed or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  9. ASP values are publicly available at a href="http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html" target="_blank">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 2014,the payment amount is based on ASP plus 6% per 42CFR 414, Subpart K; Section 112(a) Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) and Medicare Claims Processing Manual (Chapter 17, sections 20.1.2 and 20.1.3, drugs furnished incident to professional service). CMS has published (77 Fed Reg 69142, 69147) that when used in refilling an implanted intrathecal pump in the physician office, payment for the drug meets the requirements for “drugs furnished incident to a physician’s services”, rather than drugs administered through covered DME. Nonetheless, check with the local Medicare contractor or other payers for coding and billing instructions for the KD modifier for “drug or biological infused through DME” as it relates to an implanted pump.
  10. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. For catheter implantation codes 62350 and 62351, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent and NCCI edits do not allow 77003 to be coded separately.
  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. 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 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.
  14. 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.
  15. 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 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 confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. 74230-74823 (finalized December 10, 2013). The total RVU as shown here is the sum of three components: physician work RVU, 2012 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013 (signed December 26, 2013). Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
  4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.
  5. “N/A” shown in “Physician Office” setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the “Facility” RVUs at the Facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. (finalized December 10 , 2013), Addendum A: Explanation of Addendum B and C.
  6. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed, or paid when rendered by the physician who performed the surgery. These services include preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  7. The FDA has approved placing two temporary test stimulation leads during a single bilateral procedure. As defined and as published by the AMA, code 64561 represents a single lead, and when more than one lead is placed, each is coded separately. Medicare permits the use of bilateral modifier -50 or -LT/ -RT with code 64561. Medicare’s Medically Unlikely Edits allow 1 unit for code 64561. To show placement of two test leads, submit 64561-50 with 1 unit.
  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. Code 64561 is already valued to include the test lead.
  9. As defined, use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. Similarly, NCCI edits prohibit use of fluoroscopy codes with 64561 but there are no edits with 64581.
  10. 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.
  11. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  12. 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. According to CPT manual instructions, append modifier -52 to code 95972 if complex programming lasts less than 31 minutes.
  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 to code 95972 if complex programming lasts less than 31 minutes.
  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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. 74230-74823 (finalized December 10, 2013). 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013 (signed December 26, 2013). Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
  4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.
  5. “N/A” shown in Physician Office setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. (finalized December 10, 2013), Addendum A: Explanation of Addendum B and C.
  6. As published by the AMA, these codes represent a single lead. When more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 or –L T/ –RT on these codes. Although the AMA recommends appending modifier –51 to the second code when bilateral leads are placed, this may not be recognized by payers. Some providers have been able to identify to payers that each code represents a distinct lead by appending modifier -59 to the second lead code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 and 1 unit for code 63655.
  7. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 or 90 days, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  8. According to guidelines published by the AMA as well as the American Association of Neurological Surgeons use of fluoroscopy 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. For 2014, CMS established RVUs in the physician office setting for code 63650. The RVUs 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. 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.
  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.
  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.
  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. 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 to code 95972 if complex programming lasts less than 31 minutes.
  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 Final Rule 78 Fed. Reg. 74826-75200. https://federalregister.gov/a/2013-28737. Published December 10, 2013. Accessed January 30, 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; Q2 = T packaged codes, not paid separately when billed with a T procedure.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950(finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Hospital Outpatient Quality Reporting Program. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalOutpatientQualityReportingProgram.html. Accessed January 30, 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. 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://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated December 27, 2013. Accessed January 30, 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 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.
  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, (eg, rigidity, dyskinesia, tremor).
  11. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators.
  12. According to CPT manual instructions, append modifier -52 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 December 27, 2013. Accessed January 30, 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 Final Rule 78 Fed. Reg. 74826-75200. https://federalregister.gov/a/2013-28737. Published December 10, 2013. Accessed January 30, 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; Q2 = T packaged codes, not paid separately when billed with a T procedure.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950 (finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate outpatient encounter on a different date prior to the inpatient lead implantation. Further, under Medicare’s current “3-day payment window” policy, all non-diagnostic services performed during the three calendar days preceding the admission “are deemed related to the admission and thus must be billed with the inpatient stay” (Medicare Claims Processing Manual, Chapter 4, section 10.12). Note that hospital charges related to the fiducials may be rolled into the inpatient stay.
  6. 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.
  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 Reclaim™ Deep Brain Stimulation 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, (eg, rigidity, dyskinesia, tremor).
  11. The AMA has published that, notwithstanding its definition. code 95971 should be used for simple programming of deep brain neurostimulators.
  12. According to CPT manual instructions, append modifier -52 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 (Medicare Claims Processing Manual, chapter 4, section 20.6.4.A).
  1. CPT Copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Medicare Program: Hospital Outpatient Prospective Payment System Final Rule 78 Fed. Reg. 74826-75200 (finalized December 10, 2013).
  3. Status Indicator (SI) shows how a code is handled for payment purposes. N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950(finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program.

    Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. Medicare allows laparoscopic lead procedures to be performed in the hospital outpatient setting. However, open lead procedures are permitted only as inpatient and are not payable to the hospital in the outpatient setting. If performed on an outpatient basis, the hospital will not be paid for this service.
  6. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  7. According to NCCI policy, 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. 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 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 Final Rule 78 Fed. Reg. 74826-75200. https://federalregister.gov/a/2013-28737. Published December 10, 2013. Accessed January 30, 2014.
  3. Status Indicator (SI) shows how a code is handled for payment purposes. K = non-pass-through drugs, paid under separate APC; N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure. See notes 8 and 15 for status indicator Q2; see note 16 for status indicator Q1.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74590 (finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Hospital Outpatient Quality Reporting Program. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalOutpatientQualityReportingProgram.html. Accessed January 30, 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. 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. Check with the payer for specific guidelines on coding a tunneled trial catheter. Options may include 62319 to reflect the temporary nature of the trial or 62350 to reflect the tunneling even though the code definition specifies “long-term.”
  7. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device. (Centers for Medicare & Medicaid Services. National Correct Coding Initiative Edits. http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. Updated December 2, 2013. Accessed February 4, 2014.)
  8. Status Q2 indicates that device removal codes 62355 and 62365 are conditionally packaged. When submitted with another code with status “T”, such as the device implantation codes 62350-62351 and 62362, 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.
  9. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. However, fluoroscopy is designated as packaged and is not separately payable.. For catheter implantation codes 62350 and 62351, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent, and NCCI edits do not allow 77003 to be coded separately.
  10. J2275 is packaged and not separately payable. However, J2278 is designated as a “specified covered outpatient drug.” It is assigned to an APC and generates separate payment. (Centers for Medicare & Medicaid Service. Medicare Part B Drug Average Sales Price. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. Updated April 16, 2013. Accessed February 4, 2014.) CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. For 2014, the payment amount is based on ASP plus 6%. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System Final Rule 78 Fed. Reg. 74826-75200. https://federalregister.gov/a/2013-28737. Published December 10, 2013. Accessed January 30, 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 hospital ancillary staff, e.g. nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician or equivalent.
  13. 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 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.
  14. The AMA has published material confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  15. 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.
  16. Status Q1 indicates that code 76000 is conditionally packaged. Although payable in a separate APC in certain unusual circumstances, it is designated as “packaged” into the primary service when submitted with another code with status indicator “S,” “T,” “V,” or “X.” In a pump rotor study, its companion code is 62368. Because code 62368 is status “S,” code 76000 is packaged and not separately payable in this scenario.
  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. Medicare Program: Hospital Outpatient Prospective Payment System Final Rule 78 Fed. Reg. 74826-75200 (finalized December 10, 2013).
  3. Status Indicator (SI) shows how a code is handled for payment purposes. K = non-pass-through drugs, paid under separate APC; N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure. See notes 7 and 14 for status indicator Q2; see note 15 for status indicator Q1.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950(finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program.

    Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used 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. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  7. Status Q2 indicates that device removal codes 62355 and 62365 are conditionally packaged. When submitted with another code with status “T”, such as the device implantation codes 62350-62351 and 62362, 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.
  8. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. However, fluoroscopy is designated as packaged and is not separately payable. For catheter implantation codes 62350 and 62351, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent, and NCCI edits do not allow 77003 to be coded separately.
  9. 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 2014, the payment amount is based on ASP plus 6% per Medicare Program: Hospital Outpatient Prospective Payment System 78 Fed. Reg. 75028 (finalized December 10, 2013).
  10. 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.
  11. Code 62367 is used for pump interrogation only (e.g., determining the current programming, assessing the device’s functions such as battery voltage and settings, and retrieving or downloading stored data for review). Code 62368 is used when the pump is both interrogated and reprogrammed. Code 62369 is used when the pump is interrogated, reprogrammed and refilled by hospital ancillary staff, eg. Nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by a physician or equivalent.
  12. 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 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.
  13. The AMA has published material confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  14. 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.
  15. Status Q1 indicates that code 76000 is conditionally packaged. Although payable in a separate APC in certain unusual circumstances, it is designated as packaged into the primary service when submitted with another code with status indicator “S,” “T,” “V,” or “X.” In a pump rotor study, its companion code is 62368. Because code 62368 is status “S,” code 76000 is packaged and not separately payable in this scenario.
  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. Medicare Program: Hospital Outpatient Prospective Payment System Final Rule 78 Fed. Reg. 74826-75200 (finalized December 10, 2013).
  3. Status Indicator (SI) shows how a code is handled for payment purposes. N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher weighted T procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure. See note 7 for status indicator Q1.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950(finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program.

    Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. The FDA has approved placing two temporary test stimulation leads during a single bilateral procedure. As defined and as published by the AMA, code 64561 represents a single lead, and when more than one lead is placed, each is coded separately. Medicare permits the use of bilateral modifier -50 or -LT/ -RT with code 64561. Medicare’s Medically Unlikely Edits allow 1 unit for code 64561. To show placement of two test leads, submit 64561-50 with 1 unit.
  6. As defined, use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581.
  7. Status Q1 indicates that code 76000 is conditionally packaged. Although payable in a separate APC in certain unusual circumstances, it is designated as “packaged” into the primary service when submitted with another code with status indicators “S,” “T,” “V,” or “X.” When assigned with the lead implantation code, which is status “S,” code 76000 is packaged and not separately payable.
  8. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  9. According to 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.
  11. According to CPT manual instructions, append modifier -52 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 (Medicare Claims Processing Manual, chapter 4, section 20.6.4.A).
  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. Medicare Program: Hospital Outpatient Prospective Payment System Final Rule 78 Fed. Reg. 74826-75200 (finalized December 10, 2013).
  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; Q2 = T packaged codes, not paid separately when billed with a T procedure.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950(finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program.

    Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. As published by the AMA, these codes represent a single lead. When more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 or –L T/ –RT on these codes. Some providers have been able to identify to payers that each code represents a distinct lead by appending modifier -59 to the second lead code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 and 1 unit for code 63655.
  6. According to guidelines published by the AMA as well as the American Association of Neurological Surgeons use of fluoroscopy 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. 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.
  8. 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.
  9. 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.
  10. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, insertion code 63655 is assigned with removal code 63661. NCCI edits allow this combination without use of a modifier.
  11. 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.
  12. According to CPT manual instructions, append modifier -52 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 (Medicare Claims Processing Manual, chapter 4, section 20.6.4.A).
  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 FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. https://federalregister.gov/a/2013-18956. Published August 19, 2013. Accessed January 30, 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 ($5,370.28) plus the capital standard amount ($429.31). 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 FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. https://federalregister.gov/a/2013-18956. Published August 19, 2013. Accessed January 30, 2014. Tables 1A-1D. 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 FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. https://federalregister.gov/a/2013-18956. Published August 19, 2013. Accessed January 30, 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 ($5,370.28) plus the capital standard amount ($429.31). (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 FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. . Published August 19, 2013. Accessed January 30, 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.
    • Although neurostimulators are nervous system devices, implantation procedures are assigned to Mental Disorder MS-DRGs when neurostimulators are implanted for OCD.
    • 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. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2014 Final Rule, 78 Fed. Reg. 50495 - 51040 (finalized August 19, 2013).
  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 ($5,370.28) plus the capital standard amount ($429.31) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates Final Rule, 78 Fed. Reg. 50495 - 51040 (finalized August 19, 2013), Tables 1A-1D. 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. 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 Changes and FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. https://federalregister.gov/a/2013-18956. Published August 19, 2013. Accessed January 30, 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 ($5,370.28) plus the capital standard amount ($429.31). (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 FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. https://federalregister.gov/a/2013-18956. Published August 19, 2013. Accessed January 30, 2014.) Tables 1A-1D. 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. 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. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2014 Rates, Final Rule 78 Fed. Reg. 50495 - 51040 (finalized August 19, 2013).
  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 ($5,370.28) plus the capital standard amount ($429.31) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates Final Rule , 78 Fed. Reg. 51002-51003 (finalized August 19, 2013), Tables 1A-1D. 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. 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. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2014 Rates, Final Rule 78 Fed. Reg. 50495 - 51040 (finalized August 19, 2013).
  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 ($5,370.28) plus the capital standard amount ($429.31) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates Final Rule, 78 Fed. Reg. 50495-51040 (finalized August 19, 2013), Tables 1A-1D. 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. 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. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2014 Rates, Final Rule 78 Fed. Reg. 50495-51040 (finalized August 19, 2013).
  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 ($5,370.28) plus the capital standard amount ($429.31) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates Final Rule, 78 Fed. Reg. 51002-51003 (finalized August 19, 2013), Tables 1A-1D. 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. 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 two MS-DRGs for back and neck procedures with a musculoskeletal system principal diagnosis (DRGs 490 and 491); the difference is whether secondary diagnoses are designated as CCs/MCCs. However, for a whole system neurostimulator implantation in which both the leads 03.93 and the generator 86.94–86.98 are coded, MS-DRG 490 is automatically assigned regardless of whether a CC or MCC is present. For other spinal procedures, such as lead only implantation 03.93, both MS-DRGs 490 and 491 are available.
  6. The 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 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: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090. https://federalregister.gov/a/2013-28737 Published December 10, 2013. Accessed January 30, 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 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). 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, per the Medicare Claims Processing Manual; Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC. For billing bilateral neurostimulators to non-Medicare payers, contact the payer for instructions. (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 August 6, 2010. Accessed January 30, 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: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090. https://federalregister.gov/a/2013-28737 Published December 10, 2013. Accessed January 30, 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 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (Centers for Medicare & Medicaid Services. Medicare Program: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090. https://federalregister.gov/a/2013-28737 Published December 10, 2013. Accessed January 30, 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 effective January 2012 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, per the Medicare Claims Processing Manual, Chapter 14, section 40.5. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC. For 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 2014” for Medicare. All other Enterra procedures, including both open and laparoscopic lead procedures, are not on Medicare’s list of covered ASC procedures. If these procedures are performed in an ASC, Medicare makes no payment to the facility and the beneficiary is personally liable for the facility charges (Medicare Claims Processing Manual, chapter 14, section 10.2). Medicare’s list of covered surgical procedures is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ASCPayment/11_Addenda_Updates.html
  2. 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.
  3. Medicare Program: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064-75090 (finalized December 10, 2013).
  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 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  6. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for the second and all subsequent procedures. 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. For generator replacement, NCCI edits do not allow removal of the existing generator to be coded separately with implantation of the new generator. Also 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 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 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: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090. https://federalregister.gov/a/2013-28737 Published December 10, 2013. Accessed January 30, 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 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for the second and all subsequent procedures. These procedures are marked “Y.” However, procedures marked “N” are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures.
  6. For Medicare billing, ASCs use a CMS-1500 form.
  7. Injection codes 62311 and 62319 both include temporary catheter insertion. Code 62311 is used for needle injection or when a catheter is inserted 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. 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.”
  9. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  10. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. However, fluoroscopy is designated as packaged and is not separately payable. For catheter implantation code 62350, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent, and NCCI edits do not allow 77003 to be coded separately.
  11. J2275 is packaged and not separately payable. However, J2278 is designated as an “ASC covered ancillary service integral to covered surgical procedures for Calendar Year 2014” and it 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 2014, the payment amount is based on ASP plus 6% per Final Rule 78 Fed. Reg. 75028, 75083 (finalized December 10, 2013).
  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, e.g. nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician or equivalent.
  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. Medicare Program: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090 (finalized December 10, 2013).
  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 2014 ASC conversion factor is $43.4711 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). 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. 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. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  9. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. However, fluoroscopy is designated as packaged and is not separately payable. For catheter implantation code 62350, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent, and NCCI edits do not allow 77003 to be coded separately.
  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 2014” 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 2014, the payment amount is based on ASP plus 6% per 78 Fed. Reg. 75028, 75083 (finalized December 10, 2013).
  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, e.g. Nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by a physician or equivalent.
  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. Medicare Program: Ambulatory Surgical Center Payment Final Rule 78 Fed. Reg. 75064-75090 (finalized December 10, 2013). Medicare’s list of ASC covered surgical procedures and ancillary services is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html.
  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; N1 = packaged service, no separate payment.
  4. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for the second and all subsequent procedures. 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, code 64561 represents a single lead and when more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier -50 for payment in the ASC and instructs that bilateral procedures should be reported with the CPT procedure code repeated on two separate lines, or reported on a single line with units of “2” (see the Medicare Claims Processing Manual, Chapter 14, section 40.5). Medicare’s Medically Unlikely Edits allow 1 unit for code 64561. To accommodate this, ASCs can identify distinct leads to the payer by using two separate lines and appending modifier -59 to the second lead insertion code.
  8. As defined, fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581. However, although it can be coded 64581, code 76000 is designated as one of “ASC-Covered Ancillary Services Integral to Covered Surgical Procedures” and is not separately payable.
  9. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  10. 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.
  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. Medicare Program: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090 (finalized December 10, 2013).
  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 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedure and 50% of the rate for the second and all subsequent procedures. These procedures are marked “Y.” However, procedures marked “N” are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures.
  6. For Medicare billing, ASCs use a CMS-1500 form.
  7. As published by the AMA, these codes represent a single lead. When more than one lead is placed, each is coded separately. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC and instructs that bilateral procedures should be reported with the CPT procedure code repeated on two separate lines, or reported on a single line with units of “2” (see the Medicare Claims Processing Manual, Chapter 14, section 40.5). ASCs may be able to identify distinct leads to the payer by using two separate lines and appending modifier -59 to the second lead insertion code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 and 1 unit for code 63655.
  8. According to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. 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. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  9. 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.
  10. 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.
  11. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, insertion codes 63655 is assigned with removal code 63661. NCCI edits allow this combination without use of a modifier.

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 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; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule; 78 Fed. Reg. 74230-74823. https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory. Published December 10, 2013. Accessed January 29, 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013. (Centers for Medicare & Medicaid Services. MLN Connects Provider eNews—Special Edition. http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-27-standalone.pdf. Published December 27, 2013. Accessed January 30, 2014.) Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
  4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.
  5. “N/A” shown in Physician Office setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; (Centers for Medicare & Medicaid Services. Details for Regulation #: CMS-1600-FC. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1600-FC.html. Accessed January 29, 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.
  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. 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.
  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 (eg, rigidity, dyskinesia, tremor).
  15. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators.
  16. According to CPT manual instructions, append modifier -52 to code 95978 if complex programming lasts less than 31 minutes.
  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; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule; 78 Fed. Reg. 74230-74823. https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory. Published December 10, 2013. Accessed January 29, 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013. (Centers for Medicare & Medicaid Services. MLN Connects Provider eNews—Special Edition. http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-27-standalone.pdf. Published December 27, 2013. Accessed January 30, 2014.). 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 Regulation #: CMS-1600-FC. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1600-FC.html. Accessed January 29, 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.
  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. 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).
  14. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators.
  15. According to CPT manual instructions, append modifier -52 to code 95978 if complex programming lasts less than 31 minutes.
  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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. 74230-74823 (finalized December 10, 2013). 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013 (signed December 26, 2013). 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 setting then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. (finalized December 10, 2013), Addendum A: Explanation of Addendum B and C.
  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 generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  8. 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.
  9. 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.
  10. RVUs exist for this code in the non-facility (office) setting. However, they are not displayed because generator implantation and replacement customarily take place in the facility setting.
  11. According to 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.
  12. 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 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; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule; 78 Fed. Reg. 74230-74823. https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory. Published December 10, 2013. Accessed January 29, 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013. (Centers for Medicare & Medicaid Services. MLN Connects Provider eNews—Special Edition. http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-27-standalone.pdf. Published December 27, 2013. Accessed January 30, 2014.). Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
  4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.
  5. “N/A” shown in Physician Office setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. (finalized December 10, 2013), Addendum A: Explanation of Addendum B and C. “NA” shown in the Facility setting indicates that the service is not paid to the physician in a hospital or ASC, because the service is expected to be performed by employees of the hospital or ASC instead.
  6. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used 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. Check with the payer for specific guidelines on coding a tunneled trial catheter. Options may include 62350, although the code definition specifies “long-term” and the trial is temporary, or 62319 with modifier -22 to indicate that tunneling substantially increases the work.
  8. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  9. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed, or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  10. 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 2014,the payment amount is based on ASP plus 6% per 42CFR 414, Subpart K; Section 112(a) Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) and Medicare Claims Processing Manual (Chapter 17, sections 20.1.2 and 20.1.3, drugs furnished incident to professional service). CMS has published (77 Fed. Reg. 69142, 69147) that when used in refilling an implanted intrathecal pump in the physician office, payment for the drug meets the requirements for “drugs furnished incident to a physician’s services”, rather than drugs administered through covered DME. Nonetheless, check with the local Medicare contractor or other payer s for coding and billing instructions for the KD modifier for “drug or biological infused through DME” as it relates to an implanted pump.
  11. Medicare generally does not pay for supplies separately. However, other payers may make a separate payment depending on the provider contract and their payment methodology.
  12. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. For catheter implantation codes 62350 and 62351, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent, and NCCI edits do not allow 77003 to be coded separately.
  13. 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.
  14. 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.
  15. 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.
  16. Code 62369 is assigned when the pump is interrogated, reprogrammed and refilled by ancillary staff, e.g. 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, e.g. 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, e.g. nurse practitioner.
  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 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 confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  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; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule; 78 Fed. Reg. 74230-74823. https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory. Published December 10, 2013. Accessed January 29, 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013. (Centers for Medicare & Medicaid Services. MLN Connects Provider eNews—Special Edition. http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-27-standalone.pdf. Published December 27, 2013. Accessed January 30, 2014.). Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
  4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.
  5. “N/A” shown in Physician Office setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. (finalized December 10, 2013), Addendum A: Explanation of Addendum B and C. “NA” shown in the Facility setting indicates that the service is not paid to the physician in a hospital or ASC, because the service is expected to be performed by employees of the hospital or ASC instead.
  6. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used 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. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  8. Surgical procedures are subject to a “global period.” The global period defines other physician services which are generally considered part of the surgery package. The services are not separately coded, billed or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  9. ASP values are publicly available at a href="http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html" target="_blank">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 2014,the payment amount is based on ASP plus 6% per 42CFR 414, Subpart K; Section 112(a) Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) and Medicare Claims Processing Manual (Chapter 17, sections 20.1.2 and 20.1.3, drugs furnished incident to professional service). CMS has published (77 Fed Reg 69142, 69147) that when used in refilling an implanted intrathecal pump in the physician office, payment for the drug meets the requirements for “drugs furnished incident to a physician’s services”, rather than drugs administered through covered DME. Nonetheless, check with the local Medicare contractor or other payers for coding and billing instructions for the KD modifier for “drug or biological infused through DME” as it relates to an implanted pump.
  10. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. For catheter implantation codes 62350 and 62351, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent and NCCI edits do not allow 77003 to be coded separately.
  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. 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 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.
  14. 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.
  15. 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 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 confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. 74230-74823 (finalized December 10, 2013). The total RVU as shown here is the sum of three components: physician work RVU, 2012 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013 (signed December 26, 2013). Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
  4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.
  5. “N/A” shown in “Physician Office” setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the “Facility” RVUs at the Facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. (finalized December 10 , 2013), Addendum A: Explanation of Addendum B and C.
  6. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed, or paid when rendered by the physician who performed the surgery. These services include preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  7. The FDA has approved placing two temporary test stimulation leads during a single bilateral procedure. As defined and as published by the AMA, code 64561 represents a single lead, and when more than one lead is placed, each is coded separately. Medicare permits the use of bilateral modifier -50 or -LT/ -RT with code 64561. Medicare’s Medically Unlikely Edits allow 1 unit for code 64561. To show placement of two test leads, submit 64561-50 with 1 unit.
  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. Code 64561 is already valued to include the test lead.
  9. As defined, use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. Similarly, NCCI edits prohibit use of fluoroscopy codes with 64561 but there are no edits with 64581.
  10. 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.
  11. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  12. 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. According to CPT manual instructions, append modifier -52 to code 95972 if complex programming lasts less than 31 minutes.
  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 to code 95972 if complex programming lasts less than 31 minutes.
  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. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. 74230-74823 (finalized December 10, 2013). 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 2014 is $35.8228 through March 31, 2014 in accordance with the Pathway for SGR Reform Act of 2013 (signed December 26, 2013). Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
  4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.
  5. “N/A” shown in Physician Office setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule 78 Fed. Reg. (finalized December 10, 2013), Addendum A: Explanation of Addendum B and C.
  6. As published by the AMA, these codes represent a single lead. When more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 or –L T/ –RT on these codes. Although the AMA recommends appending modifier –51 to the second code when bilateral leads are placed, this may not be recognized by payers. Some providers have been able to identify to payers that each code represents a distinct lead by appending modifier -59 to the second lead code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 and 1 unit for code 63655.
  7. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 or 90 days, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.
  8. According to guidelines published by the AMA as well as the American Association of Neurological Surgeons use of fluoroscopy 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. For 2014, CMS established RVUs in the physician office setting for code 63650. The RVUs 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. 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.
  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.
  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.
  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. 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 to code 95972 if complex programming lasts less than 31 minutes.

 

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 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.

References
  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 Final Rule 78 Fed. Reg. 74826-75200. https://federalregister.gov/a/2013-28737. Published December 10, 2013. Accessed January 30, 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; Q2 = T packaged codes, not paid separately when billed with a T procedure.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950(finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Hospital Outpatient Quality Reporting Program. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalOutpatientQualityReportingProgram.html. Accessed January 30, 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. 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://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated December 27, 2013. Accessed January 30, 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 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.
  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, (eg, rigidity, dyskinesia, tremor).
  11. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators.
  12. According to CPT manual instructions, append modifier -52 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 December 27, 2013. Accessed January 30, 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 Final Rule 78 Fed. Reg. 74826-75200. https://federalregister.gov/a/2013-28737. Published December 10, 2013. Accessed January 30, 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; Q2 = T packaged codes, not paid separately when billed with a T procedure.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950 (finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate outpatient encounter on a different date prior to the inpatient lead implantation. Further, under Medicare’s current “3-day payment window” policy, all non-diagnostic services performed during the three calendar days preceding the admission “are deemed related to the admission and thus must be billed with the inpatient stay” (Medicare Claims Processing Manual, Chapter 4, section 10.12). Note that hospital charges related to the fiducials may be rolled into the inpatient stay.
  6. 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.
  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 Reclaim™ Deep Brain Stimulation 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, (eg, rigidity, dyskinesia, tremor).
  11. The AMA has published that, notwithstanding its definition. code 95971 should be used for simple programming of deep brain neurostimulators.
  12. According to CPT manual instructions, append modifier -52 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 (Medicare Claims Processing Manual, chapter 4, section 20.6.4.A).
  1. CPT Copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
  2. Medicare Program: Hospital Outpatient Prospective Payment System Final Rule 78 Fed. Reg. 74826-75200 (finalized December 10, 2013).
  3. Status Indicator (SI) shows how a code is handled for payment purposes. N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950(finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program.

    Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. Medicare allows laparoscopic lead procedures to be performed in the hospital outpatient setting. However, open lead procedures are permitted only as inpatient and are not payable to the hospital in the outpatient setting. If performed on an outpatient basis, the hospital will not be paid for this service.
  6. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  7. According to NCCI policy, 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. 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 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 Final Rule 78 Fed. Reg. 74826-75200. https://federalregister.gov/a/2013-28737. Published December 10, 2013. Accessed January 30, 2014.
  3. Status Indicator (SI) shows how a code is handled for payment purposes. K = non-pass-through drugs, paid under separate APC; N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure. See notes 8 and 15 for status indicator Q2; see note 16 for status indicator Q1.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74590 (finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. (Centers for Medicare & Medicaid Services. Hospital Outpatient Quality Reporting Program. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalOutpatientQualityReportingProgram.html. Accessed January 30, 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. 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. Check with the payer for specific guidelines on coding a tunneled trial catheter. Options may include 62319 to reflect the temporary nature of the trial or 62350 to reflect the tunneling even though the code definition specifies “long-term.”
  7. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device. (Centers for Medicare & Medicaid Services. National Correct Coding Initiative Edits. http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. Updated December 2, 2013. Accessed February 4, 2014.)
  8. Status Q2 indicates that device removal codes 62355 and 62365 are conditionally packaged. When submitted with another code with status “T”, such as the device implantation codes 62350-62351 and 62362, 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.
  9. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. However, fluoroscopy is designated as packaged and is not separately payable.. For catheter implantation codes 62350 and 62351, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent, and NCCI edits do not allow 77003 to be coded separately.
  10. J2275 is packaged and not separately payable. However, J2278 is designated as a “specified covered outpatient drug.” It is assigned to an APC and generates separate payment. (Centers for Medicare & Medicaid Service. Medicare Part B Drug Average Sales Price. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. Updated April 16, 2013. Accessed February 4, 2014.) CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. For 2014, the payment amount is based on ASP plus 6%. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System Final Rule 78 Fed. Reg. 74826-75200. https://federalregister.gov/a/2013-28737. Published December 10, 2013. Accessed January 30, 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 hospital ancillary staff, e.g. nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician or equivalent.
  13. 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 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.
  14. The AMA has published material confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  15. 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.
  16. Status Q1 indicates that code 76000 is conditionally packaged. Although payable in a separate APC in certain unusual circumstances, it is designated as “packaged” into the primary service when submitted with another code with status indicator “S,” “T,” “V,” or “X.” In a pump rotor study, its companion code is 62368. Because code 62368 is status “S,” code 76000 is packaged and not separately payable in this scenario.
  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. Medicare Program: Hospital Outpatient Prospective Payment System Final Rule 78 Fed. Reg. 74826-75200 (finalized December 10, 2013).
  3. Status Indicator (SI) shows how a code is handled for payment purposes. K = non-pass-through drugs, paid under separate APC; N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure. See notes 7 and 14 for status indicator Q2; see note 15 for status indicator Q1.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950(finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program.

    Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. Injection codes 62311 and 62319 both include temporary catheter placement. Code 62311 is used 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. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  7. Status Q2 indicates that device removal codes 62355 and 62365 are conditionally packaged. When submitted with another code with status “T”, such as the device implantation codes 62350-62351 and 62362, 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.
  8. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. However, fluoroscopy is designated as packaged and is not separately payable. For catheter implantation codes 62350 and 62351, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent, and NCCI edits do not allow 77003 to be coded separately.
  9. 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 2014, the payment amount is based on ASP plus 6% per Medicare Program: Hospital Outpatient Prospective Payment System 78 Fed. Reg. 75028 (finalized December 10, 2013).
  10. 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.
  11. Code 62367 is used for pump interrogation only (e.g., determining the current programming, assessing the device’s functions such as battery voltage and settings, and retrieving or downloading stored data for review). Code 62368 is used when the pump is both interrogated and reprogrammed. Code 62369 is used when the pump is interrogated, reprogrammed and refilled by hospital ancillary staff, eg. Nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by a physician or equivalent.
  12. 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 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.
  13. The AMA has published material confirming the use of 61070 and 75809 for implanted pump catheter dye studies.
  14. 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.
  15. Status Q1 indicates that code 76000 is conditionally packaged. Although payable in a separate APC in certain unusual circumstances, it is designated as packaged into the primary service when submitted with another code with status indicator “S,” “T,” “V,” or “X.” In a pump rotor study, its companion code is 62368. Because code 62368 is status “S,” code 76000 is packaged and not separately payable in this scenario.
  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. Medicare Program: Hospital Outpatient Prospective Payment System Final Rule 78 Fed. Reg. 74826-75200 (finalized December 10, 2013).
  3. Status Indicator (SI) shows how a code is handled for payment purposes. N = packaged into other services, not separately payable; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher weighted T procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure. See note 7 for status indicator Q1.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950(finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program.

    Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. The FDA has approved placing two temporary test stimulation leads during a single bilateral procedure. As defined and as published by the AMA, code 64561 represents a single lead, and when more than one lead is placed, each is coded separately. Medicare permits the use of bilateral modifier -50 or -LT/ -RT with code 64561. Medicare’s Medically Unlikely Edits allow 1 unit for code 64561. To show placement of two test leads, submit 64561-50 with 1 unit.
  6. As defined, use of fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581.
  7. Status Q1 indicates that code 76000 is conditionally packaged. Although payable in a separate APC in certain unusual circumstances, it is designated as “packaged” into the primary service when submitted with another code with status indicators “S,” “T,” “V,” or “X.” When assigned with the lead implantation code, which is status “S,” code 76000 is packaged and not separately payable.
  8. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  9. According to 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.
  11. According to CPT manual instructions, append modifier -52 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 (Medicare Claims Processing Manual, chapter 4, section 20.6.4.A).
  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. Medicare Program: Hospital Outpatient Prospective Payment System Final Rule 78 Fed. Reg. 74826-75200 (finalized December 10, 2013).
  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; Q2 = T packaged codes, not paid separately when billed with a T procedure.
  4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2014 is $72.672 as published in 78 Fed. Reg. 74950(finalized December 10, 2013). The conversion factor of $72.672 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program.

    Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. As published by the AMA, these codes represent a single lead. When more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier –50 or –L T/ –RT on these codes. Some providers have been able to identify to payers that each code represents a distinct lead by appending modifier -59 to the second lead code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 and 1 unit for code 63655.
  6. According to guidelines published by the AMA as well as the American Association of Neurological Surgeons use of fluoroscopy 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. 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.
  8. 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.
  9. 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.
  10. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, insertion code 63655 is assigned with removal code 63661. NCCI edits allow this combination without use of a modifier.
  11. 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.
  12. According to CPT manual instructions, append modifier -52 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 (Medicare Claims Processing Manual, chapter 4, section 20.6.4.A).

 

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 FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. https://federalregister.gov/a/2013-18956. Published August 19, 2013. Accessed January 30, 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 ($5,370.28) plus the capital standard amount ($429.31). 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 FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. https://federalregister.gov/a/2013-18956. Published August 19, 2013. Accessed January 30, 2014. Tables 1A-1D. 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 FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. https://federalregister.gov/a/2013-18956. Published August 19, 2013. Accessed January 30, 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 ($5,370.28) plus the capital standard amount ($429.31). (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 FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. . Published August 19, 2013. Accessed January 30, 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. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2014 Final Rule, 78 Fed. Reg. 50495 - 51040 (finalized August 19, 2013).
  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 ($5,370.28) plus the capital standard amount ($429.31) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates Final Rule, 78 Fed. Reg. 50495 - 51040 (finalized August 19, 2013), Tables 1A-1D. 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. 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 Changes and FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. https://federalregister.gov/a/2013-18956. Published August 19, 2013. Accessed January 30, 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 ($5,370.28) plus the capital standard amount ($429.31). (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 FY2014 Rates Final Rule, 78 Fed. Reg. 50495 - 51040. https://federalregister.gov/a/2013-18956. Published August 19, 2013. Accessed January 30, 2014.) Tables 1A-1D. 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. 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. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2014 Rates, Final Rule 78 Fed. Reg. 50495 - 51040 (finalized August 19, 2013).
  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 ($5,370.28) plus the capital standard amount ($429.31) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates Final Rule , 78 Fed. Reg. 51002-51003 (finalized August 19, 2013), Tables 1A-1D. 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. 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. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2014 Rates, Final Rule 78 Fed. Reg. 50495 - 51040 (finalized August 19, 2013).
  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 ($5,370.28) plus the capital standard amount ($429.31) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates Final Rule, 78 Fed. Reg. 50495-51040 (finalized August 19, 2013), Tables 1A-1D. 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. 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. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2014 Rates, Final Rule 78 Fed. Reg. 50495-51040 (finalized August 19, 2013).
  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 ($5,370.28) plus the capital standard amount ($429.31) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates Final Rule, 78 Fed. Reg. 51002-51003 (finalized August 19, 2013), Tables 1A-1D. 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. 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 two MS-DRGs for back and neck procedures with a musculoskeletal system principal diagnosis (DRGs 490 and 491); the difference is whether secondary diagnoses are designated as CCs/MCCs. However, for a whole system neurostimulator implantation in which both the leads 03.93 and the generator 86.94–86.98 are coded, MS-DRG 490 is automatically assigned regardless of whether a CC or MCC is present. For other spinal procedures, such as lead only implantation 03.93, both MS-DRGs 490 and 491 are available.
  6. The 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 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: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090. https://federalregister.gov/a/2013-28737 Published December 10, 2013. Accessed January 30, 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 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). 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, per the Medicare Claims Processing Manual; Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC. For billing bilateral neurostimulators to non-Medicare payers, contact the payer for instructions. (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 August 6, 2010. Accessed January 30, 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: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090. https://federalregister.gov/a/2013-28737 Published December 10, 2013. Accessed January 30, 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 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (Centers for Medicare & Medicaid Services. Medicare Program: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090. https://federalregister.gov/a/2013-28737 Published December 10, 2013. Accessed January 30, 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 effective January 2012 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, per the Medicare Claims Processing Manual, Chapter 14, section 40.5. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC. For 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 2014” for Medicare. All other Enterra procedures, including both open and laparoscopic lead procedures, are not on Medicare’s list of covered ASC procedures. If these procedures are performed in an ASC, Medicare makes no payment to the facility and the beneficiary is personally liable for the facility charges (Medicare Claims Processing Manual, chapter 14, section 10.2). Medicare’s list of covered surgical procedures is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ASCPayment/11_Addenda_Updates.html

  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. Medicare Program: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064-75090 (finalized December 10, 2013).
  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 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for the second and all subsequent procedures. 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. For generator replacement, NCCI edits do not allow removal of the existing generator to be coded separately with implantation of the new generator. Also 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. 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 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: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090. https://federalregister.gov/a/2013-28737 Published December 10, 2013. Accessed January 30, 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 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for the second and all subsequent procedures. These procedures are marked “Y.” However, procedures marked “N” are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures.
  6. For Medicare billing, ASCs use a CMS-1500 form.
  7. Injection codes 62311 and 62319 both include temporary catheter insertion. Code 62311 is used for needle injection or when a catheter is inserted 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. 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.”
  9. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  10. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. However, fluoroscopy is designated as packaged and is not separately payable. For catheter implantation code 62350, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent, and NCCI edits do not allow 77003 to be coded separately.
  11. J2275 is packaged and not separately payable. However, J2278 is designated as an “ASC covered ancillary service integral to covered surgical procedures for Calendar Year 2014” and it 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 2014, the payment amount is based on ASP plus 6% per Final Rule 78 Fed. Reg. 75028, 75083 (finalized December 10, 2013).
  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, e.g. nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by the physician or equivalent.
  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. Medicare Program: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090 (finalized December 10, 2013).
  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 2014 ASC conversion factor is $43.4711 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). 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. 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. For pump or catheter replacement, National Correct Coding (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  9. CPT manual instructions state that 77003 may be assigned separately for fluoroscopic guidance in catheter placement with injection codes 62311 and 62319, and NCCI edits allow this. However, fluoroscopy is designated as packaged and is not separately payable. For catheter implantation code 62350, guidelines from the American Association of Neurological Surgeons state that use of fluoroscopy is inherent, and NCCI edits do not allow 77003 to be coded separately.
  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 2014” 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 2014, the payment amount is based on ASP plus 6% per 78 Fed. Reg. 75028, 75083 (finalized December 10, 2013).
  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, e.g. Nurse. Code 62370 is used when the pump is interrogated, reprogrammed, and refilled by a physician or equivalent.
  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. Medicare Program: Ambulatory Surgical Center Payment Final Rule 78 Fed. Reg. 75064-75090 (finalized December 10, 2013). Medicare’s list of ASC covered surgical procedures and ancillary services is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html.
  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; N1 = packaged service, no separate payment.
  4. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for the second and all subsequent procedures. 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, code 64561 represents a single lead and when more than one lead is placed, each is coded separately. However, Medicare does not permit the use of bilateral modifier -50 for payment in the ASC and instructs that bilateral procedures should be reported with the CPT procedure code repeated on two separate lines, or reported on a single line with units of “2” (see the Medicare Claims Processing Manual, Chapter 14, section 40.5). Medicare’s Medically Unlikely Edits allow 1 unit for code 64561. To accommodate this, ASCs can identify distinct leads to the payer by using two separate lines and appending modifier -59 to the second lead insertion code.
  8. As defined, fluoroscopy is inherent to 64561 and cannot be coded separately. However, fluoroscopy can be coded separately with 64581. Similarly, National Correct Coding Initiative (NCCI) edits prohibit use of fluoroscopy codes with 64561, but there are no edits with 64581. However, although it can be coded 64581, code 76000 is designated as one of “ASC-Covered Ancillary Services Integral to Covered Surgical Procedures” and is not separately payable.
  9. For generator or lead replacement, NCCI edits do not allow removal of the existing device to be coded separately with implantation of the new device.
  10. 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.
  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. Medicare Program: Ambulatory Surgical Center Payment Final Rule, 78 Fed. Reg. 75064 - 75090 (finalized December 10, 2013).
  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 2014 ASC conversion factor is $43.471 as published in 78 Fed. Reg. 75089 (finalized December 10, 2013). Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
  5. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedure and 50% of the rate for the second and all subsequent procedures. These procedures are marked “Y.” However, procedures marked “N” are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures.
  6. For Medicare billing, ASCs use a CMS-1500 form.
  7. As published by the AMA, these codes represent a single lead. When more than one lead is placed, each is coded separately. Medicare does not recognize the use of bilateral modifier –50 for payment in the ASC and instructs that bilateral procedures should be reported with the CPT procedure code repeated on two separate lines, or reported on a single line with units of “2” (see the Medicare Claims Processing Manual, Chapter 14, section 40.5). ASCs may be able to identify distinct leads to the payer by using two separate lines and appending modifier -59 to the second lead insertion code. Note that Medicare’s Medically Unlikely Edits allow 2 units for code 63650 and 1 unit for code 63655.
  8. According to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. 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. When the same pulse generator is removed and then re-inserted, the “revision” code is used.
  9. 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.
  10. 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.
  11. The AMA has published that when a permanent percutaneous lead is removed and a new lead is placed via a fresh laminectomy at the same or a different spinal level, insertion codes 63655 is assigned with removal code 63661. NCCI edits allow this combination without use of a modifier.

 

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