COMMONLY BILLED CODES - medtronic.com · 3 DBS THERAPY COMMONLY BILLED CODES ICD-10-PCS7 Procedure Codes Hospitals use ICD-10-PCS procedure codes for inpatient services. Lead Implantation8

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COMMONLY BILLED CODES

DBS THERAPY FOR ESSENTIAL TREMOR, PARK-INSON’S DISEASE, DYSTONIA AND OBSESSIVE-COMPULSIVE DISORDER EFFECTIVE JANUARY 2018

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Medtronic provides this information for your convenience only. It does not constitute legal advice or a recommendation regarding clinical practice. Information provided is gathered from third-party sources and is subject to change without notice due to frequently changing laws, rules and regulations. The provider has the responsibility to determine medical necessity and to submit appropriate codes and charges for care provided. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other payers as to the correct form of billing or the amount that will be paid to providers of service. Please contact your Medicare contractor, other payers, reimbursement specialists and/or legal counsel for interpretation of coding, coverage and payment policies. This document provides assistance for FDA approved or cleared indications. Where reimbursement is sought for use of a product that may be inconsistent with, or not expressly specified in, the FDA cleared or approved labeling (eg, instructions for use, operator’s manual or package insert), consult with your billing advisors or payers on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service. Because Medtronic DBS Therapy for dystonia and obsessive-compulsive disorder is approved for use under a Humanitarian Device Exemption (HDE), devices can be implanted only in facilities with institutional review board (IRB) approval. The following information is calculated per the footnotes included and does not take into effect Medicare payment reductions resulting from sequestration associated with the Budget Control Act of 2011. Sequestration reductions went into effect on April 1, 2013.

ICD-10-CM1 Diagnosis Codes

Diagnosis codes are used by both physicians and hospitals to document the indication for the procedure. Medtronic Deep Brain Stimulation (DBS) Therapy is intended to manage the symptoms of the underlying conditions below. Because symptoms codes are generally not acceptable as the principal diagnosis, the principal diagnosis is coded to the underlying condition as shown.

Essential Tremor2 G25.0 Essential tremor

Parkinson’s Disease2 G20 Parkinson’s disease

Dystonia

Note: Humanitarian Device. The effectiveness of this device for the treatment of dystonia has not been demonstrated.

G24.1 Genetic torsion dystonia (dystonia deformans progressiva) (dystonia musculorum deformans) (familial torsion dystonia) (idiopathic torsion dystonia)

G24.2 Idiopathic nonfamilial dystonia (symptomatic torsion dystonia)

G24.3 Spasmodic torticollis (cervical dystonia)

G24.8 Other dystonia

G24.9 Dystonia, unspecified

Obsessive-compulsive disorder

Note: Humanitarian Device. The effectiveness of this device for the treatment of obsessive-compulsive disorder has not been demonstrated.

F42.2 Mixed obsessional thoughts and acts

F42.8 Other obsessive-compulsive disorders

F42.9 Obsessive-compulsive disorder, unspecified

FOR QUESTIONS PLEASE CONTACT US AT [email protected]

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DBS THERAPY COMMONLY BILLED CODES

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ICD-10-PCS7 Procedure Codes

Hospitals use ICD-10-PCS procedure codes for inpatient services.

Lead Implantation8 00H00MZ Insertion of neurostimulator lead into brain, open approach

00H03MZ Insertion of neurostimulator lead into brain, percutaneous approach

Generator Implantation9, 10, 11 0JH60BZ Insertion of single array stimulator generator into chest subcutaneous tissue and fascia, open approach

0JH60DZ Insertion of multiple array stimulator generator into chest subcutaneous tissue and fascia, open approach

0JH60EZ Insertion of multiple array rechargeable stimulator generator into chest subcutaneous tissue and fascia, open approach


ICD-10-CM1 Diagnosis Codes continued

Device Complications3, 4 T85.110A Breakdown (mechanical) of implanted electronic neurostimulator of brain electrode (lead)

T85.113A Breakdown (mechanical) of implanted electronic neurostimulator, generator

T85.120A Displacement of implanted electronic neurostimulator of brain electrode (lead)

T85.123A Displacement of implanted electronic neurostimulator, generator

T85.190A Other mechanical complication of implanted electronic neurostimulator of brain electrode (lead)

T85.193A Other mechanical complication of implanted electronic neurostimulator, generator

T85.731A Infection and inflammatory reaction due to implanted electronic neurostimulator of brain, electrode (lead)

T85.734A Infection and inflammatory reaction due to implanted electronic neurostimulator generator

T85.830A Hemorrhage due to nervous system prosthetic devices, implants and grafts

T85.840A Pain due to nervous system prosthetic devices, implants and grafts

T85.890A Other specified complication of nervous system prosthetic devices, implants and grafts5

Attention to Device6 Z45.42 Encounter for adjustment and management of neuropacemaker (brain, peripheral nerve, spinal cord)

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ICD-10-PCS7 Procedure Codes continued

Lead Removal8 00P00MZ Removal of neurostimulator lead from brain, open approach

00P03MZ Removal of neurostimulator lead from brain, percutaneous approach

Generator Removal10 0JPT0MZ Removal of stimulator generator from trunk subcutaneous tissue and fascia, open approach

0JPT3MZ Removal of stimulator generator from trunk subcutaneous tissue and fascia, percutaneous approach

Lead Replacement8

or Generator Replacement10 Two codes are required to identify a device replacement: one code for implantation of the new device and one code for removal of the old device.12

Lead Revision13 00W00MZ Revision of neurostimulator lead in brain, open approach

00W03MZ Revision of neurostimulator lead in brain, percutaneous approach

Generator Revision14, 15 0JWT0MZ Revision of stimulator generator in trunk subcutaneous tissue and fascia, open approach

0JWT3MZ Revision of stimulator generator in trunk subcutaneous tissue and fascia, percutaneous approach

1. Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). https://www.cdc.gov/nchs/icd/icd10cm.htm. Updated October 1, 2017. Accessed November 16, 2017.

2. Essential tremor is treated with a single array neurostimulator generator. Parkinson ’s Disease is treated with a dual array neurostimulator generator. 3. When a device complication is the reason for the encounter, the device complication code is sequenced as the primary diagnosis followed by a code for the underlying condition. If

the purpose of the encounter is directed toward the underlying condition or the device complication arises after admission, the underlying condition is sequenced as the primary diagnosis followed by the device complication code.

4. Device complication codes ending in “A” are technically defined as “initial encounter” but continue to be assigned for each encounter in which the patient is receiving active treatment for the complication (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018, I.C.19.A).

5. According to ICD-10-CM manual notes, “other specified complication” includes erosion or breakdown of a subcutaneous device pocket. 6. Code Z45.42 is used as the principal diagnosis when patients are seen for routine device maintenance, such as periodic d evice checks and programming, as well as routine device

replacement. A secondary diagnosis code is then used for the underlying condition. (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018, I.C.21.C.7). 7. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. International Classification of Diseases, Tenth Revision, Procedure Coding System

(ICD-10-PCS). http://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-and-GEMs.html. Updated October 1, 2017. Accessed November 16, 2017. 8. Approach value 0-Open is used when leads are placed via craniotomy or craniectomy. Placement of a lead via burr hole is considered a percutaneous approach and uses approach

value 3-Percutaneous (Coding Clinic, 3rd Q 2017, p.13; see also CMS ICD-10-PCS Reference Manual 2016, p.47). The same rationale can be applied to lead removal and replacement.

9. Codes defined as “multiple array” include dual array neurostimulator generators, a type of multiple array generator in which two leads are connected to one generator. Activa SC is a single-array non-rechargeable generator (device value B), Activa PC is a dual-array non-rechargeable generator (device value D), and Activa RC is a dual-array rechargeable generator (device value E). See also the ICD-10-PCS Device Index. Do not assign default device value M-Stimulator Generator.

10. Placement of a neurostimulator generator is shown with the approach value 0-Open because creating the pocket requires surgical dissection and exposure. Removal also usually requires surgical dissection to free the device.

11. Body part value 6-Chest is shown because the generator is typically placed into the subcutaneous tissue of the chest. Other body part values are also available for sites such as subcutaneous tissue of abdomen and subcutaneous tissue of back.

12. CMS ICD-10-PCS Reference Manual 2016, p.67. 13. For lead revision, the ICD-10-PCS codes refer to surgical revision of the intracranial portion of the lead, eg, repositioning. For revision of the subcutaneous portion of the lead or

revision of a subcutaneous extension, see Generator Revision. 14. The ICD-10-PCS codes shown can be assigned for opening the pocket for generator revision, as well as reshaping or relocating the pocket while reinserting the same generator.

However, there are no ICD-10-PCS codes specifically defined for revising the subcutaneous portion of a lead or an extension. Because these services usually involve removing and reinserting the generator as well, they can also be represented by the generator revision codes.

15. Approach value X-External is also available for external generator manipulation without opening the pocket, eg. to correct a flipped generator.

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HCPCS II Device Codes1 (Non-Medicare)

These codes are used by the entity that purchased and supplied the medical device, DME, drug, or supply to the patient. For implantable devices, that is generally the facility. For specific Medicare hospital outpatient billing instructions for medical devices, see the Device C-Codes (Medicare) below.

Note: The HCPCS II code for the lead is not shown because intracranial leads are not implanted on an outpatient basis.

Pulse Generator2 L8679 Implantable neurostimulator pulse generator, any type

L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension

L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

Patient Programmer L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

External Recharger L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

1. Healthcare Common Procedure Coding System (HCPCS) Level II codes are maintained by the Centers for Medicare and Medicaid Services. http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html Accessed November 21, 2017.

2. Effective January 2014, generator codes L8686-L8688 are not recognized by Medicare. Specifically for billing Medicare, code L8679 is available for physician use, while hospitals typically use C-codes and ASCs generally do not submit HCPCS II codes for devices. For non-Medicare payers, codes L8686-L8688 remain available. However, all providers should check with the payer for specific coding and billing instructions.

Device C-Codes1 (Medicare)

Medicare provides C-codes for hospital use in billing Medicare for medical devices in the outpatient setting. Although other payers may also accept C-codes, regular HCPCS II device codes are generally used for billing non-Medicare payers. Unlike regular HCPCS II device codes, the extension is coded separately using C-codes. ASCs, however, usually should not assign or report HCPCS II device codes for devices on claims sent to Medicare. Medicare generally does not make a separate payment for devices in the ASC. Instead, payment is “packaged” into the payment for the ASC procedure. ASCs are specifically instructed not to bill HCPCS II device codes to Medicare for devices that are packaged.2

Note: The C-code for the lead is not shown because intracranial leads are not implanted on an outpatient basis.

Pulse Generator C1767 Generator, neurostimulator (implantable), non-rechargeable

C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system

Extension C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable)

Patient Programmer C1787 Patient programmer, neurostimulator

1. Device C-codes are HCPCS Level II codes and are maintained by the Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System. http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html. Accessed November 21, 2017.

2. ASCs should report all charges incurred. However, only charges for non-packaged items should be billed as separate line items. For example, the ASC should report its charge for the generator. However, because the generator is a packaged item, the charge should not be reported on its own line. Instead, the ASC should bill a single line for the implantation procedure with a single total charge, including not only the charge associated with the operating room but also the charges for the generator device and all other packaged items. Because of a Medicare requirement to pay the lesser of the ASC rate or the line-item charge, breaking these packaged charges out onto their own lines can result in incorrect payment to the ASC. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14—Ambulatory Surgical Centers, Section 40. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf. Accessed November 21, 2017. See also MLN Matters SE0742 p.9-10: Centers for Medicare and Medicaid Services. MLN Matters Number SE0742 Revised. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0742.pdf. Accessed November 21, 2017.


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Medtronic DBS for Essential Tremor and Parkinson’s Disease

Device Edits (Medicare)1

Medicare’s procedure-to-device edits require that when certain CPT® procedure codes for device implantation are submitted on a hospital outpatient bill, HCPCS II codes for devices must also be billed. Effective January 2015, the edits are broadly defined and may include any HCPCS II device code with any CPT procedure code used in earlier versions of the edits.2 Within this context, the HCPCS II device codes shown below are both appropriate for the CPT procedure codes and will pass the edits.

CPT Procedure Code

CPT Code Description3 HCPCS ll Device Codes

HCPCS ll Code Description

618854,5 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array

C1767 Generator, neurostimulator (implantable), non-rechargeable

618865 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays

C1767 Generator, neurostimulator (implantable), non-rechargeable

C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system

1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule.82 Fed. Reg. 52474-52475 https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf . Published November 13, 2017. Accessed November 21, 2017.

2. Centers for Medicare & Medicaid Services. Device and Procedure Edits. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Archives.html. Last updated April 10, 2013. Accessed November 2, 2017.

3. CPT copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

4. In practice, HCPCS device code C1820 is not appropriate with CPT procedure code 61885 because rechargeable dual-array generators are used only with procedure code 61886. 5. HCPCS II L-codes L8686-L8688 will also pass the edits, but these codes are not shown because they are not otherwise recognized by Medicare. HCPCS II device code L8679 does

not satisfy the edits.


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Physician Coding and Payment — January 1, 2018– December 31, 2018

CPT® Procedure Codes

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

Procedure CPT Code and Description1 Medicare RVUs2

Medicare National Average3

For physician services provided in:4

Physician Office5

Facility Physician Office5

Facility

Bone Marker Fiducial Placement6

— — — — —

Diagnostic Imaging and Planning7,8

70450-26 CT, head or brain; without contrast material9

— 1.21 — $44

70551-26 MRI, brain (including brain stem); without contrast material9

— 2.12 — $76

76376-26 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality, with image post-processing under concurrent supervision, not requiring image post processing on an independent workstation9

— 0.28 — $10

76377-26 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality, with image post-processing under concurrent supervision, requiring image post processing on an independent workstation9

— 1.13 — $41

61863 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array

N/A 43.89 N/A $1,580 Lead Implantation10, 11

61864 each additional array (List separately in addition to primary procedure.)

N/A 8.37 N/A $301

61867 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array

N/A 66.69 N/A $2,401

61868 each additional array (List separately in addition to primary procedure.)

N/A 14.73 N/A $530



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Physician Coding and Payment continued




Physician Office5


Facility

Generator Implantation or Replacement10,12

61885 (Activa® SC) Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array

N/A 14.94 N/A $538

61886 (Activa® RC, Activa® PC) Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays

N/A 24.58 N/A $885

For bilateral stimulation via implantation of two Activa® SC single array pulse generators, one on each side connected to a single lead, use 61885-50 for the generators plus 61863 and 61864 or 61867 and 61868 for the leads.13

For bilateral stimulation via implantation of one Activa® RC or one Activa® PC dual array pulse generator with connection to two leads, use 61886 for the generator plus 61863 and 61864 or 61867 and 61868 for the leads.

Bilateral stimulation is not performed for essential tremor, but is performed for Parkinson’s Disease.

Intraoperative Stimulation with Microelectrode Recording14

95961-26 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of attendance by physician or other qualified healthcare professional9

— 4.61 — $166

95962-26 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional hour of attendance by physician or other qualified healthcare professional (List separately in addition to code for primary procedure.)9

— 4.95 — $178

61880 Revision or removal of intracranial neurostimulator electrodes

N/A 16.55 N/A $596 Revision or Removal of Leads or Generator10,11, 12 61888 Revision or removal of cranial

neurostimulator pulse generator or receiver N/A 11.58 N/A $417



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Physician Office5


Facility

Analysis and Programming Note: In the office, analysis and programming may be furnished by a physician, practitioner with an “incident to” benefit, or auxiliary personnel under the direct supervision of the physician (or other practitioner), with or without support from a manufacturer’s representative. The patient or payer should not be billed for services rendered by the manufacturer’s representative. Contact your local contractor or payer for interpretation of applicable policies.

95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord or peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming

1.97 0.69 $71 $25

95971 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming15,16

1.45 1.17 $52 $42

95978 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming, first hour15,17

7.17 5.51 $258 $198

95979 each additional 30 minutes after first hour (List separately in addition to code for primary procedure.)

3.08 2.55 $111 $92



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2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018 Final Rule; 82 Fed. Reg. 52976-53371. https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf Published November 15, 2017. Accessed November 21, 2017. 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 2018 is $35.9996 per 82 Fed. Reg. 53344. https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953. Published November 15, 2017. Accessed November 21, 2017. See also the January 2018 release of the PFS Relative Value File RVU18A at http:/www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html. Released November 15, 2017. Accessed November 21, 2017. Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.

4. The RVUs shown are for the physician’s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. “Facility” includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the “Facility” setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the “Physician Office” setting because the physician incurs all costs there.

5. “N/A” shown in Physician Office setting indicates that Medicare has not developed RVUs in the office setting because the service is typically performed in a facility (eg, in a hospital). However, if the local contractor determines that it will cover the service in the office, then it is paid using the facility RVUs at the facility rate. Centers for Medicare & Medicaid Services. Details for Title: CMS-1676-F. CY 2018 PFS Final Rule Addenda. Addendum A: Explanation of Addendum B and C. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-F.html . Released November 6, 2017. Accessed November 21, 2017.

6. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate encounter, in the physician’s office, and/or on a different date prior to the lead implantation. CPT Assistant, October 2010, p.9.

7. Pre-operative CT and MRI imaging may be separately coded when they represent full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately. Note that although CPT code 61781 exists for computer-assisted intradural surgical navigation, CPT manual instructions and National Correct Coding Initiative (NCCI) edits do not allow this to be coded separately with lead implantation codes 61863 and 61867.

8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure. 9. This assumes the service is occurring in the hospital facility, because the primary lead procedure must be performed in a facility. So the physician is providing the professional

interpretation only (-26) and only facility RVUs and payments are displayed. 10. Surgical procedures are subject to a “global period.” The global period defines other physician services that are generally considered part of the surgery package. The services are

not separately coded, billed, or paid when rendered by the physician who performed the surgery. These services include: preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure , treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal.

11. When an existing lead is removed and replaced by a new lead, only the lead implantation code 61863-61867 may be assigned. For lead replacement, NCCI edits do not permit removal of the existing lead to be coded separately with placement of the new lead.

12. When an existing generator is removed and replaced by a new generator, only the generator replacement code 61885 or 61886 may be assigned. NCCI edits do not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used. NCCI Policy Manual 1/1/2018, p. VIII-8.

13. Medicare permits the use of bilateral modifier -50 with code 61885. To show bilateral placement of two single-array generator leads, submit 61885-50 with 1 unit. Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf. Released August 15, 2014. Accessed November 3, 2017. See also Medicare Claims Processing Manual, Chapter 12—Physicians/Nonphysician Practitioners, section 40.7.B. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed November 3, 2017. See also NCCI Policy Manual 1/1/2018, p. I-39.

14. As defined, microelectrode recording is included in lead implantation codes 61867-61868. CPT manual instructions and NCCI edits do not allow 95961-95962 to be coded separately with lead implantation when microelectrode recording is performed by the operating surgeon. However, the AMA has published that when another physician (eg, neurologist or neurophysiologist) performs the cortical or subcortical mapping during the placement of the electrode array, that physician may report codes 95961-95962 separately. CPT Changes 2004: An Insider’s View, p.93.

15. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), assessing more than one clinical feature (eg, rigidity, dyskinesia, tremor). (See also CPT Assistant, July 2016, p.7 and p.9.)

16. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15.

17. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes.



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Hospital Outpatient Coding and Payment — Effective January 1, 2018 – December 31, 2018


Hospitals use CPT codes for outpatient services. Under Medicare’s APC methodology for hospital outpatient payment, each CPT code is assigned to one of approximately 710 ambulatory payment classes. Each APC has a relative weight that is then converted to a flat payment amount. Multiple APCs can sometimes be assigned for each encounter, depending on the number of procedures coded and whether any of the procedure codes map to a Comprehensive APC.

For 2018, there are 61 APCs which are designated as Comprehensive APCs (C-APCs). Each CPT procedure code assigned to one of these C-APCs is considered a primary service, and all other procedures and services coded on the bill are considered adjunctive to delivery of the primary service. This results in a single APC payment and a single beneficiary copayment for the entire outpatient encounter, based solely on the primary service. Separate payment is not made for any of the other adjunctive services. Instead, the payment level for the C-APC is calculated to include the costs of the other adjunctive services, which are packaged into the payment for the primary service.

When more than one primary service is coded for the same outpatient encounter, the codes are ranked according to a fixed hierarchy. The C-APC is then assigned according to the highest ranked code. In some special circumstances, the combination of two primary services leads to a “complexity adjustment” in which the entire encounter is re-mapped to another higher-level APC.

As shown on the tables below, DBS therapies are subject to C-APCs specifically for implantation, replacement, revision and removal of the generator. C-APCs are identified by status indicator J1.

Note: Only procedures that can be performed in the hospital outpatient setting are shown. Intracranial lead implantation is not shown because it is not performed on an outpatient basis.

Procedure CPT Code and Description1 APC2 APC Title2 SI2,3 Relative Weight2

Medicare National

Average2,4

Bone Marker Fiducial Placement5

— — — — — —

Diagnostic Imaging6 and Planning

70450 CT, head or brain without contrast material7

5522 Level 2 Imaging without Contrast

S 1.4556 $114

70551 MRI, brain (including brain stem), without contrast material7

5523 Level 3 Imaging without Contrast

S 2.9543 $232

76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision, not requiring image post-processing on an independent workstation8

N/A N/A N N/A N/A

76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision, requiring image post-processing on an independent workstation8

N/A N/A N N/A N/A



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Hospital Outpatient Coding and Payment continued


Medicare National

Average2,4

Generator Implantation or Replacement9

61885 (Activa® SC) Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array

5463 Level 3 Neurostimulator and Related Procedures

J1 233.5939 $18,369

61886 (Activa® RC, Activa® PC) Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays


J1 354.6949 $27,892

For bilateral stimulation via implantation or replacement of two Activa® SC single array pulse generators, one on each side connected to a single lead, use 61885-50 or 61885 plus 61885-59.10 For bilateral stimulation via implantation or replacement of one Activa® RC or one Activa® PC dual array pulse generator with connection to two leads, use 61886.11 Under Comprehensive APCs for 2018, use of 61885-50 or 61885 plus 61885-59 for the same encounter does not qualify for a complexity adjustment. When either 61885-50 is submitted or 61885 plus 61885-59 is submitted to show that two generators were placed bilaterally, the entire encounter remains under APC 5463. Bilateral stimulation is not performed for essential tremor, but is performed for Parkinson’s Disease.

Revision or Removal of Leads or Generator9



Q2 36.6165 $2,879

61888 Revision or removal of cranial neurostimulator pulse generator or receiver


J1 77.0081 $6,056



13



Medicare National Average2,4

Analysis and Programming Note: In the hospital, analysis and programming may be furnished by a physician or other practitioner, with or without support from a manufacturer’s representative. Neither the payer or patient should be billed for services rendered by the manufacturer’s representative. Contact your local contractor or payer for interpretation of applicable policies.

95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming

5734 Level 4 Minor Procedures Q1 1.3358 $105

95971 Electronic analysis of implanted neurostimulator pulse generator system, (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming 12,13

5742 Level 2 Electronic Analysis of Devices

S 1.4647 $115

95978 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour 12,14

5742 Level 2 Electronic Analysis of Devices

S 1.4647 $115

95979 each additional 30 minutes after first hour (List separately in addition to code for primary procedure.)

N/A N/A N N/A N/A



14


2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems..Final Rule. 82 Fed. Reg. 52356-52637. https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf Published November 13, 2017. Accessed November 21, 2017. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 82 FR 61184..https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf. Published December 27, 2017. Accessed January 5, 2018.

3. Status Indicator (SI) shows how a code is handled for payment purposes: J1 = paid under a comprehensive APC, single payment based on primary service without separate payment for other adjunctive services; N = packaged service, no separate payment; S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higher-weighted T procedure; Q1 = STV packaged codes, not paid separately when billed with an S, T, or V procedure; Q2 = T packaged codes, not paid separately when billed with a T procedure. See note 7 for status indicator Q3.

4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2018 is $78.636. The conversion factor of $78.636 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Reporting Program. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems... Final Rule.82 Fed. Reg. 52398. https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf Published November 13, 2017. Accessed November 21, 2017. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 82 FR 61184..https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf. Published December 27, 2017. Accessed January 5, 2018. Payment is adjusted by the wage index for each hospital’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.

5. The AMA has published that placement of fiducials is integral to DBS lead implantation and is not coded separately. This is true even if the fiducials are placed during a separate outpatient encounter on a different date prior to the inpatient lead implantation. CPT Assistant, October 2010, p.9. Further, under Medicare’s current “3-day payment window” policy, all non-diagnostic services performed during the three calendar days preceding the admission “are deemed related to the admission and thus must be billed … with the inpatient stay”. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 10.12. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated April 22, 2015. Accessed November 21, 2017. Note that hospital charges related to the fiducials may be rolled into the inpatient stay.

6. Pre-operative CT and MRI imaging may be coded separately when they represent full-scale diagnostic imaging and the interpretation is documented via a formal imaging report. However, some payers may require imaging guidance codes such as 77011 and 77021 instead. Intra-operative imaging is part of surgical navigation and should not be coded separately.

7. More broadly, these codes have status indicator Q3. For CT and MRI, status indicator Q3 shows that the service may be part of a composite APC if billed with other similar imaging services. However, within the context of services related to Medtronic DBS Therapy, the codes will generally be paid separately under the APCs, status indicators, and rates shown.

8. The 3D rendering codes are reported in addition to the code for the base CT or MRI procedure. However, they are packaged into APC payment for the base imaging and are not separately payable.

9. When an existing generator is removed and replaced by a new generator, only the generator replacement code 61885 or 61886 may be assigned. NCCI edits do not allow removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for generator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used. (NCCI Policy Manual 1/1/2018, p. VIII-8).

10. Medicare permits the use of bilateral modifier -50 with code 61885. To show bilateral placement of two single-array generator leads, submit 61885-50 with 1 unit. Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf. Released August 15, 2014. Accessed November 21, 2017. See also Medicare Claims Processing Manual, Chapter 4—Part B Hospital, sections 20.6 and 20.6.2. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf . Accessed November 21, 2017. See also NCCI Policy Manual , 1/1/2018, p. I-39. Alternately, because some payers may not recognize the bilateral modifier, providers may consider using 61885 plus 61885-59. Medicare’s Medically Unlikely Edits allow 2 units for code 61885 on the same date of service.

11. See AHA’s Coding Clinic for HCPCS, 3rd Q 2011, p.10 for bilateral stimulation via a dual array neurostimulator generator. 12. According to CPT manual instructions, “simple” programming involves changes to three or fewer parameters and “complex” programming involves changes to four or more

parameters. The parameters that qualify are: rate, pulse amplitude, pulse duration, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train spacing, number of programs, number of channels, alternating electrode polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), assessing more than one clinical feature, (eg, rigidity, dyskinesia, tremor). (See also CPT Assistant, July 2016, p.7 and p.9.)

13. The AMA has published that, notwithstanding its definition, code 95971 should be used for simple programming of deep brain neurostimulators. CPT Assistant, October 2012, p.15.

14. According to CPT manual instructions, append modifier -52 for reduced services to code 95978 if complex programming lasts less than 31 minutes. For hospital outpatient reporting, modifier -52 is used to indicate partial reduction of services for which anesthesia is not planned. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 4—Part B Hospital, Section 20.6.4.A. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Updated December 22, 2016. Accessed November 21, 2017.



15


Hospital Inpatient Coding and Payment — Effective October 1, 2017 – September 30, 2018

MS-DRG Assignments : Essential Tremor, Parkinson’s Disease, and Dystonia

Under Medicare’s MS-DRG methodology for hospital inpatient payment, each inpatient stay is assigned to one of about 755 diagnosis-related groups, based on the ICD-10-CM codes assigned to the diagnoses and ICD-10-PCS codes assigned to the procedures. Each MS-DRG has a relative weight that is then converted to a flat payment amount. Only one MS-DRG is assigned for each inpatient stay, regardless of the number of procedures performed. The MS-DRGs shown are those typically assigned to the following scenarios.

Procedure Scenario MS-DRG1

MS-DRG Title1,2 Relative Weight1


Implantation and Replacement : Whole System

Whole system implant or replacement: - single array generator plus lead

025 Craniotomy and Endovascular Intracranial Procedures W MCC

4.3064 $25,952

026 Craniotomy and Endovascular Intracranial Procedures W CC

2.9971 $18,062

027 Craniotomy and Endovascular Intracranial Procedures W/O CC/MCC

2.3665 $14,262

Whole system implant or replacement: - multiple array non-rechargeable generator plus lead(s) - multiple array rechargeable generator plus lead(s)

023 Craniotomy with Major Device Implant or Acute CNS Principal Diagnosis W MCC or Chemo Implant or Epilepsy W Neurostimulator

5.4949 $33,115

024 Craniotomy with Major Device Implant/ Acute Complex CNS Principal Diagnosis W/O MCC

3.8314 $23,090

Implantation and Replacement : Generator only or Lead only

Generator only implant or replacement (any type)

040 Peripheral/Cranial Nerve and Other Nervous System Procedures W MCC

3.8078 $22,948

041 Peripheral/Cranial Nerve and Other Nervous System Procedures W CC or Peripheral Neurostimulator

2.3311 $14,048

042 Peripheral/Cranial Nerve and Other Nervous System Procedures W/O CC/MCC

1.9105 $11,514

Lead only implant or replacement


4.3064 $25,952


2.9971 $18,062


2.3665 $14,262

Removal (without replacement)4


4.3064 $25,952 Whole system removal: - generator (any type) plus lead(s) 5


2.9971 $18,062


2.3665 $14,262


16

Hospital Inpatient Coding and Payment continued

MS-DRG Assignments : Essential Tremor, Parkinson’s Disease, and Dystonia




Removal (without replacement)4

Generator only removal (any type)

These codes are not considered “significant procedures” for the purpose of DRG assignment. A non-surgical (ie, medical) DRG is assigned to the stay according to the principal diagnosis.

Lead only removal 025 Craniotomy and Endovascular Intracranial Procedures W MCC

4.3064 $25,952


2.9971 $18,062


2.3665 $14,262

Revision Lead revision6 025 Craniotomy and Endovascular Intracranial Procedures W MCC

4.3064 $25,952


2.9971 $18,062


2.3665 $14,262

Generator revision These codes are not considered “significant procedures” for the purpose of DRG assignment. A non-surgical (ie, medical) DRG is assigned to the stay according to the principal diagnosis.

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 FY2018 Rates Final Rule, 82 Fed. Reg. 37990-38589. https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf. Published August 14, 2017. Accessed September 21, 2017 and Correction 82 Fed. Reg. 46138-46163 https://www.gpo.gov/fdsys/pkg/FR-2017-10-04/pdf/2017-21325.pdf. Published October 4, 2017. Accessed October 5, 2017.

2. W MCC in MS-DRG titles refers to secondary diagnosis codes that are designated as major complications or comorbidities. MS-DRGs W MCC have at least one major secondary complication or comorbidity. Similarly, W CC in MS-DRG titles refers to secondary diagnosis codes designated as other (non-major) complications or comorbidities, and MS-DRGs W CC have at least one other (non-major) secondary complication or comorbidity. MS-DRGs W/O CC/MCC have no secondary diagnoses that are designated as complications or comorbidities, major or otherwise. Note that some secondary diagnoses are only designated as CCs or MCCs when the conditions were present on admission, and do not count as CCs or MCCs when the conditions are acquired in the hospital during the stay.

3. Payment is based on the average standardized operating amount ($5,572.53) plus the capital standard amount ($453.95). 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 FY2018 Rates; 82 Fed. Reg. 38548. Tables 1A-1D. https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf. Published August 14, 2017. Accessed September 21, 2017 and Correction 82 Fed. Reg. 46146 https://www.gpo.gov/fdsys/pkg/FR-2017-10-04/pdf/2017-21325.pdf. Published October 4, 2017. Accessed October 5, 2017. The payment rate shown is the standardized amount for facilities with a wage index greater than one. The average standard amounts shown also assume facilit ies receive the full quality update. The payment will also be adjusted by the Wage Index for specific geographic locality. Therefore, payment for a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.

4. Procedures involving device removal without replacement, particularly for generators, are frequently performed as outpatient. They are shown here for the occasional scenario where removal takes place as an inpatient.

5. When the generator and leads are removed together, the lead removal code is the “driver” and groups to the DRGs shown. 6. For Lead Revision, the DRGs reflect surgical revision of the intracranial portion of the lead, eg, repositioning a displaced lead within brain tissue.


17

Hospital Inpatient Coding and Payment — Effective October 1, 2017 – September 30, 2018

MS-DRG Assignments : Obsessive–Compulsive Disorder

Under Medicare’s MS-DRG methodology for hospital inpatient payment, each inpatient stay is assigned to one of about 755 diagnosis-related groups, based on the ICD-10-CM codes assigned to the diagnoses and ICD-10-PCS codes assigned to the procedures. Each MS-DRG has a relative weight that is then converted to a flat payment amount. Only one MS-DRG is assigned for each inpatient stay, regardless of the number of procedures performed. The MS-DRGs shown are those typically assigned to the following scenarios.




Implantation and Replacement : Whole System4

Whole system implant or replacement : - generator (any type) plus lead(s)

876 OR Procedure W Principal Diagnoses of Mental Illness

3.5094 $21,149

Implantation and Replacement : Generator only or Lead only4

Generator only implant or replacement (any type)


3.5094 $21,149

Lead(s) only implant or replacement


3.5094 $21,149

Removal (without replacement)5, 6

Entire system removal: - generator (any type) plus lead(s)7


4.3064 $25,952


2.9971 $18,062


2.3665 $14,262

Generator only removal (any type)

These codes are not considered “significant procedures” for the purpose of DRG assignment. A non-surgical (ie, medical) DRG is assigned to the stay according to the principal diagnosis.

Lead(s) only removal 025 Craniotomy and Endovascular Intracranial Procedures W MCC

4.3064 $25,952


2.9971 $18,062


2.3665 $14,262

Revision6 Lead revision8 025 Craniotomy and Endovascular Intracranial Procedures W MCC

4.3064 $25,952


2.9971 $18,062


2.3665 $14,262

Generator revision These codes are not considered “significant procedures” for the purpose of DRG assignment. A non-surgical (ie, medical) DRG is assigned to the stay according to the principal diagnosis.


18

Hospital Inpatient Coding and Payment continued

MS-DRG Assignments : Obsessive–Compulsive Disorder

1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Pro-spective Payment System Changes and FY2018 Rates Final Rule, 82 Fed. Reg. 37990-38589. https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf. Published August 14, 2017. Accessed September 21, 2017 and Correction 82 Fed. Reg. 46138-46163 https://www.gpo.gov/fdsys/pkg/FR-2017-10-04/pdf/2017-21325.pdf. Published October 4, 2017. Accessed October 5, 2017.

2. W MCC in MS-DRG titles refers to secondary diagnosis codes that are designated as major complications or comorbidities. MS-DRGs W MCC have at least one major secondary complication or comorbidity. Similarly, W CC in MS-DRG titles refers to secondary diagnosis codes designated as other (non-major) complications or comorbidities, and MS-DRGs W CC have at least one other (non-major) secondary complication or comorbidity. MS-DRGs W/O CC/MCC have no secondary diagnoses that are designated as complications or comorbidities, major or otherwise. Note that some secondary diagnoses are only designated as CCs or MCCs when the conditions were present on admission, and do not count as CCs or MCCs when the conditions are acquired in the hospital during the stay.

3. Payment is based on the average standardized operating amount ($5,572.53) plus the capital standard amount ($453.95). 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 FY2018 Rates; Fed. Reg. 38548. Tables 1A-1D. https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf. Published August 14, 2017. Accessed September 21, 2017 and Correction 82 Fed. Reg. 46146 https://www.gpo.gov/fdsys/pkg/FR-2017-10-04/pdf/2017-21325.pdf. Published October 4, 2017. Accessed October 5, 2017. The payment rate shown is the standardized amount for facilities with a wage index greater than one. The average standard amounts shown also assume facilit ies 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 the diagnosis of obsessive-compulsive disorder.

5. Procedures involving device removal without replacement, particularly for generators, are frequently performed as an outp atient. They are shown here for the occasional scenario where removal take place as an inpatient.

6. Because neurostimulators are nervous system devices, removal and revision procedures are assigned to Nervous System MS -DRGs in scenarios where neurostimulators are revised or removed for diagnoses involving device complications.

7. When the generator and leads are removed together, the lead removal code is the “driver” and groups to the DRGs shown. 8. For Lead Revision, the DRGs reflect surgical revision of the intracranial portion of the lead, eg, repositioning a displaced lead within brain tissue.


19

ASC Coding and Payment — Effective January 1, 2018 – December 31, 2018

Essential Tremor and Parkinson’s Disease*


ASCs use CPT codes for their services. Medicare payment for procedures performed in an ambulatory surgery center is generally based on Medicare’s ambulatory patient classification (APC) methodology for hospital outpatient payment. However, Comprehensive APCs (C-APCs) are used only for hospital outpatient services and are not applied to procedures performed in ASCs. Alternately, payment for some CPT codes is based on the physician fee schedule payment, particularly for procedures commonly performed in the physician office.

Each CPT code designated as a covered procedure in an ASC is assigned a comparable 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.

Procedure CPT Code and Description1 Payment Indicator2,3,4

Multiple Procedure

Discounting5

Relative Weight2,4

Medicare National

Average2,4,6

Generator Implantation or Replacement7

61885 (Activa® SC) Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling, with connection to a single electrode array

J8 N 360.2747 $16,420

61886 (Activa® RC, Activa® PC) Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling, with connection to 2 or more electrode arrays

J8 N 506.9858 $23,106

For bilateral stimulation via implantation or replacement of two Activa® SC single array pulse generators, one on each side connected to a single lead, report 61885 twice. This can be with 61885 repeated on two separate lines, or on a single line with units of 2.8 For bilateral stimulation via implantation or replacement of one Activa® RC or one Activa® PC dual array pulse generator with connection to two leads, use 61886.9

Bilateral stimulation is not performed for essential tremor, but is performed for Parkinson’s Disease.

Revision or Removal of Leads or Generator7


G2 N 32.9109 $1,500

61888 Revision or removal of cranial neurostimulator pulse generator or receiver

G2 N 68.0259 $3,100


20


* DBS generator procedures for essential tremor and Parkinson’s Disease may be performed in ASCs. Because DBS therapy for dystonia and obsessive-compulsive disorder is approved under a Humanitarian Device Exemption, devices can only be placed in facilities with a Institutional Review Board.

1. CPT copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. Applicable FARS/DFARS

Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 82 Fed. Reg. 52541-52564. https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf Published November 13, 2017. Accessed November 21, 2017. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 82 FR 61184..https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf. Published December 27, 2017. Accessed January 5, 2018.

3. The Payment Indicator shows how a code is handled for payment purposes. J8 = device-intensive procedure, payment amount adjusted to incorporate device cost; G2 = surgical procedure, non-office-based, payment based on hospital outpatient rate adjusted for ASC.

4. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2018 ASC conversion factor is $45.575. The conversion factor of $45.575 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems... Final Rule. 82 Fed. Reg. 52561. https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf Published November 13, 2017. Accessed November 21, 2017. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 82 FR 61184..https://www.gpo.gov/fdsys/pkg/FR -2017-12-27/pdf/2017-27949.pdf. Published December 27, 2017. Accessed January 5, 2018. 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 61885 or 61886 may be assigned. NCCI edits do not allow

removal of the existing generator to be coded separately. Also note that, according to NCCI policy, use of the CPT code for g enerator “insertion or replacement” requires placement of a new pulse generator. When the same pulse generator is removed and then re-inserted, the “revision” code is used. (NCCI Policy Manual 1/1/2018, p. VIII-8).

8. These instructions for billing bilateral neurostimulators are for Medicare claims. Medicare does not recognize the use of bi lateral modifier -50 for payment in the ASC and instructs that bilateral procedures should either be reported with the CPT procedure code repeated on two separate lines, or reported on a single line with units of “2”. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14—Ambulatory Surgery Centers, section 40.5: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf. Updated May 23, 2008. Accessed November 21, 2017. See also Centers for Medicare and Medicaid Services. Transmittal 1421, CR 8853, 4-General Processing Instructions. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf. Released August 15, 2014. Accessed November 21, 2017. For billing bilateral neurostimulators to non-Medicare payers, contact the payer for instructions.

9. See AHA’s Coding Clinic for HCPCS, 3rd Q 2011, p.10 for bilateral stimulation via a dual array neurostimulator generator.

ASC Coding and Payment continued

21

DBS THERAPY FOR ESSENTIAL TREMOR AND PARKINSON’S DISEASE COMMONLY BILLED CODES

Medtronic Inc. 710 Medtronic Pkwy Minneapolis, MN 55432 USA Tel. 1-763-505-5000

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COMMONLY BILLED CODES - medtronic.com · 3 DBS THERAPY COMMONLY BILLED CODES ICD-10-PCS7 Procedure Codes Hospitals use ICD-10-PCS procedure codes for inpatient services. Lead Implantation8