Reimbursement Guidelines for Pain Management Proceduresoecsurgerylearning.gehealthcare.com/files/flexpaper/F34B3D20-8407... · Reimbursement Guidelines for Pain Management Procedures

GE Healthcare

Reimbursement Guidelines for Pain Management Procedures1

April 2015

www.gehealthcare.com/reimbursement

This overview addresses coding, coverage, and payment for pain management procedures when performed in the hospital outpatient, inpatient department, as well as the physician’s office. While this advisory focuses on Medicare program policies, these policies may also be applicable to selected private payers throughout the country.

The following provides 2015 national Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Ambulatory Payment Category (APC) payment rates. Payment will vary in geographic locality.

2015 National Average MPFS and APC Reimbursement for Pain Management Procedures

CPT2 /HCPCS Code

Physician Facility

Reimbursement Component

Medicare Physician

Fee Schedule Amount3

APC Hospital Outpatient Payment4

Injection Spine

62280 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid

Facility* $163.86

0207 $672.06Non Facility** $306.87

62281 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic

Facility $158.830203 $1470.03

Non Facility $239.32

62282 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Facility $151.640203 $1470.03


62284 Injection procedure for myelography and/or computed tomography, lumbar

Facility $89.83N/A Bundled

ServiceNon Facility $187.21

62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar

Facility $592.90

0221 $2947.54

Non Facility N/A

62290 Injection procedure for discography, each level



62291 Injection procedure for discography, each level; cervical or thoracic



62292 Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels

Facility $603.320203 Bundled Service –No

Separate PaymentNon Facility N/A

62294 Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal


Separate PaymentNon Facility N/A

62302 Myelography via lumbar injection, including radiological supervision and interpretation; cervical


Separate PaymentNon Facility $249.74

62303 Myelography via lumbar injection, including radiological supervision and interpretation; thoracic



62304 Myelography via lumbar injection, including radiological supervision and interpretation



62305 Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (eg, lumbar/thoracic, cervical/ thoracic, lumbar/cervical, lumbar/thoracic/ cervical)

Facility $133.67

0274 $826.95


62310 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

Facility $112.47

0207 Bundled Service –No Separate Payment


62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)

Facility $92.71

0207 $672.06


62318 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

Facility $102.77

0207 $672.06


62319 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)

Facility $99.18

0207 $672.06


Catheter Implantation

62270 Spinal puncture, lumbar, diagnostic Facility $81.57

0206 $372.76


62272 Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility $87.680206 $372.76


62273 Injection, epidural, of blood or clot patch

Facility $117.860207 $672.06


62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy

Facility $417.19

0224 $3662.54

Non Facility N/A

62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy

Facility $904.09

0208 $4113.17

Non Facility N/A

62355 Removal of previously implanted intrathecal or epidural

Facility $281.360203 $1470.03

Non Facility N/A

Reservoir/Pump Implantation

62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir

Facility $316.930224 $3662.54

Non Facility N/A

62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump

Facility $453.120227 $15,572.43

Non Facility N/A

95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed

Facility N/A

0439 $173.59

Non Facility $91.27

95991 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care professional

Facility $40.25

0439 $173.59


Reservoir/Pump Implantation

62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir

Facility $315.360224 $3662.54

Non Facility N/A

62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump

Facility $450.87

0227 $15,572.43

Non Facility N/A

95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed

Facility N/A

0439 $173.59Non Facility $90.82

95991 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care professional

Facility $40.05

0439 $173.59


Intrathecal or Epidural Drug Infusion Pump Implantation

62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming

Facility $403.17

0227 $15,572.43

Non Facility N/A

62365 Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion

Facility $310.82

0221 $2947.54

Non Facility N/A

62367 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill

Facility $25.87

0691 $247.54

Non Facility $41.68

62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming

Facility $36.29

0691 $247.54

Non Facility $57.85

62369 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill

Facility $36.65

0691 $247.54


62370 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill (requiring skill of a physician or other qualified health care professional)

Facility $48.51

0691 $247.54


Neurostimulators (Spinal)

63650 Percutaneous implantation of neurostimulator electrode array, epidural

Facility $427.25

0061 $5290.65


63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

Facility $869.23

0039 $17,106.04

Non Facility N/A

63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

Facility $333.46

0229 $1,384.07


63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

Facility $880.73

0688 $2,128.81

Non Facility N/A

63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

Facility $468.21

0061 $5,290.65


63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

Facility $900.85

0061 $5,290.65

Non Facility N/A

63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling

Facility $382.33

0318 $26,162.39

Non Facility N/A

63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver

Facility $385.93

0688 $2,128.81

Non Facility N/A

Introduction/Injection of anesthetic Agent (Nerve Block), Diagnostic or TherapeuticSomatic Nerves

64400 Injection, anesthetic agent; trigeminal nerve, any division or branch

Facility $73.300204 $211.21


64402 Injection, anesthetic agent; facial nerve

Facility $80.850420 $131.75


64405 Injection, anesthetic agent; greater occipital nerve

Facility $65.400206 $372.76


64408 Injection, anesthetic agent; vagus nerve

Facility $88.760204 $211.21


64410 Injection, anesthetic agent; phrenic nerve

Facility $70.790204 $211.21


64412 Injection, anesthetic agent; spinal accessory nerve

Facility $74.380206 $372.76


64413 Injection, anesthetic agent; cervical plexus

Facility $85.160206 $372.76


64415 Injection, anesthetic agent; brachial plexus, single

Facility $66.840206 $372.76


64416 Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement)

Facility $81.570207 $672.06

Non Facility N/A

64417 Injection, anesthetic agent; axillary nerve

Facility $72.590206 $372.76


64418 Injection, anesthetic agent; suprascapular nerve

Facility $79.410206 $372.76


64420 Injection, anesthetic agent; intercostal nerve, single

Facility $70.070206 $372.76


64421 Injection, anesthetic agent; intercostal nerves, multiple, regional block

Facility $94.510207 $672.06


64425 Injection, anesthetic agent; ilioinguinal, iliohypogastric

Facility $95.940206 $372.76


64430 Injection, anesthetic agent; pudendal nerve

Facility $85.880207 $672.06


64435 Injection, anesthetic agent; paracervical (uterine) nerve

Facility $86.240206 $372.76


64445 Injection, anesthetic agent; sciatic nerve, single

Facility $74.380207 $672.06


64446 Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement)

Facility $81.930207 $672.06

Non Facility N/A

64447 Injection, anesthetic agent; femoral nerve, single

Facility $67.910206 $372.76


64448 Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement)

Facility $72.940203 $1470.03

Non Facility N/A

64449 Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement)

Facility $86.24

0207 $672.06Non Facility N/A

64450 Injection, anesthetic agent; other peripheral nerve or branch

Facility $47.070206 $372.76

Non Facility $81.93

64455 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton’s neuroma)

Facility $35.570204 $211.21

Non Facility $48.51

64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level

Facility $137.27

0207 $672.06


+64480 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

Facility $65.40

N/A BundledService


64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level

Facility $116.78

0207 BundledService

Service $223.51

+64484 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Facility $53.54

N/A BundledService

Non Facility $89.12

64486 (New code as of 2015)Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed)

Facility $65.04

N/A BundledService


64487 (New code as of 2015)Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by continuous infusion(s) (includes imaging guidance, when performed

Facility $74.74

N/A BundledService


64488 (New code as of 2015)Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed)

Facility $81.57

N/A BundledService


64489 (New code as of 2015)Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by continuous infusions (includes imaging guidance, when performed

Facility $91.63

N/A BundledService


Paravertebral Spinal Nerves and Branches

64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

Facility $110.68

0207 BundledService


+64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)

Facility $62.52

N/A BundledService

Non Facility $96.30

+64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

Facility $63.24

N/A BundledService

Non Facility $96.66

64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

Facility $94.51

0207 $672.06


+64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)

Facility $53.90

N/A BundledService

Non Facility $88.76

+64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

Facility $54.62

N/A BundledService

Non Facility $89.12

Autonomic Nerves

64505 Injection, anesthetic agent; sphenopalatine ganglion

Facility $89.470204 $211.21


64508 Injection, anesthetic agent; carotid sinus (separate procedure)

Facility $75.820204 $211.21

Non Facility $64.68

64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic)

Facility $76.180207 $672.06


64517 Injection, anesthetic agent; superior hypogastric plexus

Facility $126.490207 $672.06


64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)

Facility $83.720207 $672.06


64530 Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring

Facility $95.580207 $672.06


Destruction by Neurolytic Agent

64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

Facility $234.650203 $1,470.03


+64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

Facility $70.43

N/A BundledService


64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

Facility $231.77

0203 $1,470.03


+64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Facility $62.16

N/A Bundled Service


Musculoskeletal Injections

20552 Injection(s); single or multiple trigger point(s),1 or 2 muscle(s)

Facility $38.810204 $211.21

Non Facility $56.06

20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s)

Facility $44.200204 $211.21

Non Facility $65.04

20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)

Facility $36.650204 $211.21

Non Facility $48.51

20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting

Facility $47.430204 $211.21

Non Facility $73.66

20605 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance

Facility $38.09

0204 $211.21

Non Facility $50.67

20606 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting

Facility $54.26

0204 $211.21

Non Facility $81.57

20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance

Facility $47.43

0204 $211.21

Non Facility $61.45

20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting

Facility $63.96

0204 $211.21

Non Facility $94.15

64999 Unlisted procedure, nervous systemFacility Carrier

Priced 0204 $211.21Non Facility Carrier

Priced

Ultrasound-related Category III Codes

0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level

Facility Carrier Priced

0207 $672.06

Non Facility Carrier Priced

+0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)


N/A Bundled


+0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)


N/A Bundled


0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level


0207 $672.06


+0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure)


N/A Bundled


+0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

Facility Carrier Priced N/A Bundled

0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level


0207 $672.06


+0229T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure)


N/A Bundled


0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single


0207 $672.06Facility Carrier

Priced

+0231T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)


N/A Bundled


Vertebroplasty

22510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic

Facility $471.45

0050 $2602.13


22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral

Facility $442.70

0050 $2602.13


22512 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)

Facility $219.91

N/A Bundled


Kyphoplasty

22510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic

Facility $471.45

0050 $2602.13


22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral

Facility $442.70

0050 $2602.13


22512 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)

Facility $219.91

N/A Bundled


Fluoroscopic Guidance

77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

Professional*** $28.39N/A

BundledTechnical**** $64.68

Global $93.07

77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)

Professional $30.90

0204 $211.21Technical $55.34

Global $86.24

Ultrasound Guidance

76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

Professional $33.78

N/A BundledTechnical $27.31

Global $61.09

* Facility – is the payment made to the physician when the procedure is performed in a hospital or ASC.** Non-Facility – is the payment to the physician when the procedure is performed in the physician’s office.*** Professional (-26) - The professional component is the interpretation of the results of the test. When the professional component is reported separately the service may be identified by adding modifier 26.****Technical (-TC) - The technical component is the equipment and technician performing the test. This is identified by adding modifier “TC” to the procedure code identified for the technical component charge.+ indicates add-on code

Modifiers

Modifiers explain that a procedure or service was changed without changing the definition of the CPT code set. Here are some common modifiers related to the use of pain management procedures. This is not an all-inclusive list of applicable modifiers. Refer to your current CPT and/or HCPCS manual for a complete list of modifiers and instructions for specific CPT codes.

-22- Increased Procedural ServicesThis modifier would be appended to the appropriate CPT code when the work required to provide a service is substantially greater than typically required. Documentation must support the additional work and the reason for it .

-50 - Bilateral ProceduresBilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5-digit code. Do not append this modifier if bilateral service is identified in the listings/description of the CPT code itself.

-51 – Multiple ProceduresBilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5-digit code. Do not append this modifier if bilateral service is identified in the listings/description of the CPT code itself.

-52 – Reduced ServicesWhen a service or procedure is partially reduced or eliminated at the physician’s discretion, modifier –52 would be appended to the applicable procedure code.

-53 – Discontinued ProcedureThe physician may choose to terminate a surgical or diagnostic procedure in certain circumstances. If the procedure was started and then discontinued, the modifier –53 would be appended to the procedure code.

-59 – Distinct Procedural ServiceThis modifier is used when it is necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. This modifier may be used with procedure codes that aren’t usually billed together, but may be due to certain circumstances.

-76 – Repeat Procedure or Service by Same PhysicianThis modifier would be used when it a procedure or service was repeated subsequent to the original procedure or service.

-77 – Repeat Procedure by Another PhysicianThis modifier is used to indicate that a procedure or service performed by another physician was repeated. -78 – Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period When another unplanned procedure was performed during the postoperative period of the initial procedure, this modifier would be appended to the procedure code.

Hospital Inpatient - ICD-9-CM Procedure CodingICD-9-CM procedure codes are used to report procedures performed in a hospital inpatient setting. The following are ICD-9-CM procedure codes that are commonly used to report pain management procedures in the inpatient setting (not all inclusive):

ICD-9-CM Description03.8 Injection of destructive agent into spinal canal 03.90 Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances 03.91 Injection of anesthetic into spinal canal for analgesia 03.92 Injection of other agent into spinal canal 03.93 Implantation or replacement of spinal neurostimulator lead(s) 03.94 Removal of spinal neurostimulator lead(s)03.96 Percutaneous denervation of facet 03.99 Other operations on spinal cord and spinal canal structures 04.81 Injection of anesthetic into peripheral nerve for analgesia

05.31 Injection of anesthetic into sympathetic nerve for analgesia 76.96 Injection of therapeutic substance into temporomandibular joint 81.91 Arthrocentesis 81.92 Injection of therapeutic substance into joint or ligament 82.92 Aspiration of bursa of hand 82.94 Injection of therapeutic substance into bursa of hand 82.95 Injection of therapeutic substance into tendon of hand 82.96 Other injection of locally-acting therapeutic substance into soft tissue of hand 83.94 Aspiration of bursa 83.96 Injection of therapeutic substance into bursa 83.98 Injection of locally acting therapeutic substance into other soft tissue 86.05 Incision with removal of foreign body or device from skin and subcutaneous tissue 86.06 Insertion of totally implantable infusion pump 86.09 Other incision of skin and subcutaneous tissue86.94 Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable 86.95 Insertion or replacement of multiple array neurostimulator pulse generator, not specified as rechargeable 86.96 Insertion or replacement of other neurostimulator pulse generator 87.21 Contrast myelogram 87.22 Other x-ray of cervical spine 87.23 Other x-ray of thoracic spine 87.24 Other x-ray of lumbosacral spine 87.29 Other x-ray of spine 88.38 Other computerized axial tomography 88.39 X-ray, other and unspecified 88.79 Other diagnostic ultrasound 89.39 Other nonoperative measurements and examinations 99.23 Injection of steroid 99.29 Injection or infusion of other therapeutic or prophylactic substance

ICD-9-CM Diagnosis Coding

Because of the vast array of diagnoses related to the aforementioned procedures, please check with your payer regarding appropriate ICD-9-CM diagnosis code selection.

MS-DRG Medicare Reimbursement

The following table lists some of the common Medicare MS-DRGs associated with pain management procedures and their 2015 National Average reimbursement rates. Please note that the final MS-DRG assignment will be based on the combination of ICD-9-CM diagnosis and procedure codes as well as the presence, or lack of, complications and/or co-morbidities. Only one MS-DRG is assigned to a patient for a particular hospital admission.

MS-DRG Description 2015 Medicare Rate 023 Craniotomy with Major Device Implant/Acute Complex Central Nervous

System Principal Diagnosis with MCC or Chemo Implant $31,090.37

024 Craniotomy with Major Device Implant/Acute Complex Central Nervous System Principal Diagnosis without MCC

$22,000.28

029 Spinal Procedures with CC or Spinal Neurostimulator $18,542.53040 Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC $22,293.07

DISCLAIMER

THE INFORMATION PROVIDED WITH THIS NOTICE IS GENERAL REIMBURSEMENT INFORMATION ONLY; IT IS NOT LEGAL ADVICE, NOR IS IT ADVICE ABOUT HOW TO CODE, COMPLETE OR SUBMIT ANY PARTICULAR CLAIM FOR PAYMENT. IT IS ALWAYS THE PROVIDER’S RESPONSIBILITY TO DETERMINE AND SUBMIT APPROPRIATE CODES, CHARGES, MODIFIERS AND BILLS FOR THE SERVICES THAT WERE RENDERED. THIS INFORMATION IS PROVIDED AS OF JANUARY 1, 2015 AND ALL CODING AND REIMBURSEMENT INFORMATION IS SUBJECT TO CHANGE WITHOUT NOTICE. PAYERS OR THEIR LOCAL BRANCHES MAY HAVE DISTINCT CODING AND REIMBURSEMENT REQUIREMENTS AND POLICIES. BEFORE FILING ANY CLAIMS, PROVIDERS SHOULD VERIFY CURRENT REQUIREMENTS AND POLICIES WITH THE LOCAL PAYER. THIRD PARTY REIMBURSEMENT AMOUNTS AND COVERAGE POLICIES FOR SPECIFIC PROCEDURES WILL VARY INCLUDING BY PAYER, TIME PERIOD AND LOCALITY, AS WELL AS BY TYPE OF PROVIDER ENTITY. THIS DOCUMENT IS NOT INTENDED TO INTERFERE WITH A HEALTH CARE PROFESSIONAL’S INDEPENDENT CLINICAL DECISION MAKING. OTHER IMPORTANT CONSIDERATIONS SHOULD BE TAKEN INTO ACCOUNT WHEN MAKING DECISIONS, INCLUDING CLINICAL VALUE. THE HEALTH CARE PROVIDER HAS THE RESPONSIBILITY, WHEN BILLING TO GOVERNMENT AND OTHER PAYERS (INCLUDING PATIENTS), TO SUBMIT CLAIMS OR INVOICES FOR PAYMENT ONLY FOR PROCEDURES WHICH ARE APPROPRIATE AND MEDICALLY NECESSARY. YOU SHOULD CONSULT WITH YOUR REIMBURSEMENT MANAGER OR HEALTHCARE CONSULTANT, AS WELL AS EXPERIENCED LEGAL COUNSEL.

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

$12,490.00

042 Peripheral/Cranial Nerve and Other Nervous System Procedures without CC/MCC

$10,915.32

518 Back and Neck Procedures Except Spinal Fusion with MCC or Disc Device/Neurostimulator

$17,987.55

579 579 Other Skin, Subcutaneous Tissue and Breast Procedures with MCC $16,011.09580 Other Skin, Subcutaneous Tissue and Breast Procedures with CC $9,236.25581 Other Skin, Subcutaneous Tissue and Breast Procedures without CC/MCC $6,658.76

Documentation Requirements

As with all medical procedures performed, the following requirements should be met in order to be considered for coverage and reimbursement by Medicare:

• Medical necessity as determined by the payer• Completeness• Documented in the patient’s medical record

Coverage Policies

Medicare carriers may issue local coverage decisions (LCDs) addressing the requirements that must be met for services to be covered. It is strongly recommended that physicians review these LCDs or contact their local payers to inquire about these requirements. Medicare LCDs may be found at this link: http://www.cms.gov/medicare-coverage-database/ Coverage by private payers varies by payer and by plan. It is important that you contact the payer prior to submitting claims to determine their requirements.

1. Information presented in this document is current as of January 1, 2015. Any subsequent changes which may occur in coding, coverage and payment are not reflected herein.

2. Current Procedural Terminology (CPT) is copyright 2014 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.

3. Third party reimbursement amounts and coverage policies for specific procedures will vary by payer and by locality. The MPFS payment is based on relative value units published in Federal Register/Vol. 79, No. 219 /Thursday, November 13, 2014 as well as subsequent updates and legislation. Amounts do not necessarily reflect any subsequent changes in payment since publication. The fee schedule amounts indicated are effective for services provided from 7/1/15 through 12/31/15 only. To confirm reimbursement rates for specific codes, consult with your local Medicare contractor

4. Third party reimbursement amounts and coverage policies for specific procedures will vary by payer and by locality. The technical component is a payment amount assigned to an Ambulatory Payment Classification under the hospital outpatient prospective payment system, as published in Federal Register/Vol. 79, No. 217 / November 10 2014. The professional component is generally paid based on the Medicare physician fee schedule. Amounts do not necessarily reflect any subsequent changes in payment since publication. To confirm reimbursement rates for specific codes, consult with your local Medicare contractor.

5. Federal Register/ Vol. 79, No. 163 / Friday, August 27, 2014

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Documents

Reimbursement Guidelines for Pain Management Proceduresoecsurgerylearning.gehealthcare.com/files/flexpaper/F34B3D20-8407... · Reimbursement Guidelines for Pain Management Procedures