If you do qualify for this test under Medicare, your cover will pay 100 percent of the cost of the test if you use a licensed Medicare-approved provider that accepts assignment.
Full Answer
Are peripheral neurostimulators reimbursable by Medicare?
For much of the past decade, peripheral neurostimulator devices have been used liberally by some practitioners to treat chronic pain. In addition to pain relief, any manufacturers also promise providers that these devices are reimbursable by Medicare. This combination of relief and reimbursement has proven irresistible.
How much does a neurostimulation procedure cost?
Practitioners would bill around $1,000 per procedure using this code. The American Medical Association (AMA) defines Code 64555 as a “ percutaneous implantation of neurostimulator electrode array, peripheral nerve (excludes sacral nerve).”
How common are Medicare payment errors in neurostimulator implantation?
Those reviews found payment error rates as high as 72 percent. Our objective was to determine whether health care providers complied with Medicare requirements when they billed for neurostimulator implantation surgeries.
Does Medicare cover electrical nerve stimulators (SCS)?
CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, §160.7, Electrical Nerve Stimulators. The implantation of spinal cord stimulators (SCS) may be covered as therapies for the relief of chronic intractable pain.
Does Medicare pay for removal of spinal cord stimulator?
Most private insurance companies cover some or all of the costs of spinal cord stimulators. But for those that are on Medicare, it's not uncommon to wonder if you will be covered. Luckily, there is good news. Traditional Medicare does cover spinal cord stimulators, and the procedures to implant them in the body.
How do I bill CPT 63650?
Use CPT code 63650 for the permanent percutaneous epidural implantation of the neurostimulator electrode array. This is the same code as used for the temporary lead placement. If placing a second lead, the provider will bill 63650 for the first lead. The second lead is billed using the 59 modifier.
How do you code a spinal cord stimulator trial?
CPT code 63650 is not altered when the implantation of the percutaneous epidural neurostimulator electrode is performed for the purpose of a "temporary" trial or for "permanent" neurostimulation.
Is L8680 covered by Medicare?
For neurostimulator devices, HCPCS code L8680 is no longer separately billable for Medicare because payment for electrodes has been incorporated in CPT code 63650 Percutaneous implantation of neurostimulator electrode array, epidural.
Can CPT 63650 be billed twice?
Question: If bilateral spinal electrode are placed percutaneously, 63650, can both be reported? Answer: Yes, if two electrodes are placed, bilaterally, both may be reported.
Is 63650 a bilateral code?
Expert. Per Medicare Physician Fee Schedule, 63650 can not be billed as bilateral. It carries a "0" bilateral status indicator. Per CPT Assistant, additional arrays inserted would be reported with 51 modifier.
Does Medicare cover CPT 63685?
CPT® codes 63685 and 63688 are temporarily removed from the list of services that require Medicare prior authorization when performed in a hospital outpatient department.
How often are batteries replaced in a spinal cord stimulator?
The average battery life for rechargeable spinal cord stimulators is 7-10 years (compared to 2-5 years for non-rechargeable). Fewer replacements: Many people can go more than ten years before needing a replacement. This means people with a rechargeable battery undergo fewer replacement surgeries.
Can 63661 be billed twice?
CPT 63661 has array(s) in the plural form; thus, removal of one or multiple leads would only be reported with one unit of service.
Does Medicare cover dorsal root ganglion stimulation?
"While Medicare already covers our DRG system, it's encouraging to see private payers like Aetna review the clinical data and outcomes, then choose to provide access to DRG stimulation for their members.
What is the difference between CPT 63685 and 63688?
CPT® codes 63685 (insertion or replacement of spinal neurostimulator pulse generator or receiver) and 63688 (revision or removal of implanted spinal neurostimulator pulse generator or receiver) are temporarily removed from the list of services that require Medicare prior authorization when performed in a hospital ...
What is CPT L8680?
L8680 is a valid 2022 HCPCS code for Implantable neurostimulator electrode, each or just “Implt neurostim elctr each” for short, used in Lump sum purchase of DME, prosthetics, orthotics.
Does Medicare cover spinal cord stimulators?
Luckily, there is good news. Traditional Medicare does cover spinal cord stimulators, and the procedures to implant them in the body. Because the science behind spinal cord stimulators is sound, Medicare is willing and able to cover the procedure and its hardware for those that qualify.
Do spinal cord stimulators work?
Spinal Cord Stimulators Do Work. The science behind spinal cord stimulators is clear. While it is one of many treatments available for chronic pain, it is one that is supposed by the medical community and thus covered by most common forms of Medicare to those that qualify.
Document Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act (SSA), §1862 (a) (1) (A), states that no Medicare payment shall be made for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, §160.7, Electrical Nerve Stimulators..
Coverage Guidance
The implantation of spinal cord stimulators (SCS) may be covered as therapies for the relief of chronic intractable pain. SCS is best suited for neuropathic pain but may have some limited value in other types of nociceptive severe, intractable pain.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
Background Sacral Nerve Stimulation for urinary incontinence is covered for the treatment of urinary urge incontinence, urge-frequency syndrome, and urinary retention by the CMS National Coverage Determination (NCD) 230.18, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf.
ICD-10-CM Codes that Support Medical Necessity
Note: The “C” codes listed above are only applicable when billed under the hospital outpatient prospective payment system (OPPS) and they should be submitted in place of codes A4290.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
How much did the Georgia chiropractor pay in 2020?
A medical practice had been ordered to pay more than $4.3 million, and the practice’s owner and chiropractor ordered to pay $700,000, to resolve claims that they billed Medicare for implantation of hundreds of P-Stim devices.
Where are needle electrodes placed in APNS?
Unlike PENS, where the needle electrodes are placed in proximity to the nerve serving the area of chronic pain, in APNS the placement of the needles is based on the flow of the person’s life-giving force called ‘qi’ (pronounced ‘chee’).
What is the HCPCS code for pulse generator?
HCPCS Code L8679 is the device code for an “implantable neurostimulator, pulse generator.” 5 This is the code to claim reimbursement for the device itself. The device was priced at $10,000 for which Medicare reimbursed around $6,500.
Can a peripheral neurostimulator be reimbursed by Medicare?
In addition to pain relief, any manufacturers also promise providers that these devices are reimbursable by Medicare. This combination of relief and reimbursement has proven irresistible.
Does Medicare reimburse neurostim?
Medicare rules do not allow for reimbursement of these devices and never have. Providers who submit these neurostim claims to the Centers for Medicare and Medicaid Services (CMS) are submitting false claims to the government. The government has taken notice and is cracking down.
Is peripheral nerve stimulation covered by a physician?
Therefore, it is covered only when performed by a physician or incident to physician’s service.
Does Medicare cover acupuncture?
The FDA classifies PENS and APNS devices as electro-acupuncture devices. Medicare does not cover acupuncture for any condition other than chronic low back pain. 2 But that did not stop manufacturers from implying, or outright misrepresenting to providers, that these devices were legally reimbursable.
How many electrodes are in a spinal cord stimulator?
A spinal cord stimulator consists of two electrodes and a battery pack similar to a pacemaker. For the trial procedure, a single tiny incision is made to insert the electrodes into the epidural space of the spine while the battery remains outside of the body. Over a short period of time, patients can determine if spinal cord stimulation helps them ...
How long does a spinal cord stimulator last?
A spinal cord stimulator trial period is at least 5 to 7 days.
Why are spinal cord stimulators used?
Since the spinal cord is responsible for transmitting sensory and motor information from the brain to the rest of the body, injuries and complications can result in debilitating pain and severe mobility problems. Spinal cord stimulators have been developed as a treatment for patients who have exhausted conservative treatment options without finding ...
Can you use a spinal stimulator for back pain?
Although not every spine condition is best treated with a spinal cord stimulator, commonly treated conditions include: Chronic back pain and leg pain due to age-related conditions like arthritis or degenerative disc disease. Complications related to previous spine surgery, also known as failed back surgery syndrome (FBSS) ...
Is spinal cord stimulation reversible?
One study reports that 24% of patients improved sufficiently to return to gainful employment or housework with stimulation alone or with the addition of occasional oral pain medication. Unlike a spinal fusion, a spinal cord stimulator surgery is reversible.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act, §1833 (e). Prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.
Article Guidance
The following billing and coding guidance is to be used with its associated Local Coverage Determination.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
Document Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act (SSA), §1862 (a) (1) (A), states that no Medicare payment shall be made for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, §160.7, Electrical Nerve Stimulators..
Coverage Guidance
Peripheral nerve stimulation (PNS) may be covered for relief of chronic intractable pain for patients with conditions known to be responsive to this form of therapy, and only after attempts to cure the underlying conditions and appropriate attempts at medication management, physical therapy, psychological therapy and other less invasive interdenominational treatments.
Types of Nerve Stimulation
Obfuscation and Deception
- The FDA classifies PENS and APNS devices as electro-acupuncture devices. Medicare does not cover acupuncture for any condition other than chronic low back pain.2But that did not stop manufacturers from implying, or outright misrepresenting to providers, that these devices were legally reimbursable. Providers were encouraged to use certain codes to report APNS to Medica…
Providers in The Dark
- Sales representatives for these electro-acupuncture devices knew they could sell more devices if the providers thought they could get reimbursed. When the providers started asking questions, some manufacturers doubled-down. They brought in consultants to coach providers on how to document the procedure in the medical records and code the treatment so that Medicare would …
Medicare Crackdown
- Based on these “stealth coding” practices advocated by some manufacturers, Medicare reimbursed many providers as if they had performed an implantation procedure of an implanteddevice. CMS was slow to recognize the improper coding but responded early enough that manufacturers and sales representatives knew that these procedures and devices were not …
Recoveries by The Department of Justice and Office of Inspector General
- CMS, the Department of Justice (DOJ), and the Office of Inspector General (OIG) have initiated False Claims Act prosecutions to recoup payments for electro-acupuncture treatments. The number and frequency of these actions are increasing. In most cases, recoupment starts with a CMS audit of medical and billing records for claims involving CPT 64555 and HCPCS L8679. At t…
Conclusion
- Medicare rules do not allow for reimbursement of electro-acupuncture devices and never have. Providers who file these claims with CMS under the guise of implantedneurostimulators are submitting false claims to the government. The government has taken notice and is actively targeting providers to recoup payments. The number of False Claims Act settlements has increa…