Procedure Documentation Guide for SCS

1 Quick reference Guide on Precision Spinal Cord Stimulation (SCS) System Procedure Documentation Neuromodulation Procedure Documentation Guide for SCS Trial Procedure CPT Codes1,2,3 63650, L8680 (if performed in POS 11) Device Documentation4 1 or 2 leads (electrode array) 8 or 16 electrodes (contacts) Permanent Procedure : Percutaneous Lead(s) CPT Codes1,2,3 63650, 63685 Device Documentation4 1 or 2 leads (electrode array) 8 or 16 electrodes (contacts) Dual array rechargeable implantable pulse generator Permanent Procedure : Paddle Lead CPT Codes1,2,3 63655, 63685 Device Documentation4 1 lead (electrode array) 16 electrodes (contacts) Dual array rechargeable implantable pulse generator Programming* CPT Codes 95971 (simple), 95972 (complex, first hour), 95973 (complex, each additional 30 minutes) Device Documentation5 Simple: Three or fewer changes in programming parameters Complex: Greater than three changes in programming parameters Document Time: Programming is time based, use modifier 52 for programming time less than 31 minutes with 95972 See back page for important information about the uses and limitations of this document.

2 NM-48611-AA Rate Pulse Amplitude Pulse Duration Pulse Frequency Cycling Stimulation train duration Train spacing Number of programs Number of channels Alternating electrode polarities Dose time Eight or more electrode contacts 2012 Programming Parameters * A physician should not bill if the service is performed entirely by, under the direction of, a manufacturer representative without payer consent. If the service is performed in part by the physician or the physician-supervised personnel (in accordance with the Medicare incident to requirements) and in part by a manufacturer representative, the physician should contact the payer and/or a reimbursement consultant before billing the services. 1 CPT Copyright 2011 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association.

3 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 CPT Assistant April 2011/Volume 21 Issue 4 3 North American Spine Society, 2011 Common Coding Scenarios for Comprehensive Spine Care pg: 171-173. 4 Document add-on component(s) when applicable ( , Clik anchor, extension, splitter) 5 For 2012, AMA CPT interprets simple intraoperative or subsequent programming (95971) to be changes to three or fewer of the patient programming parameters. When changes occur to more than three of the patient programming parameters, this is linked to complex intraoperative or subsequent programing (95972-95973).

4 6 Medicare National Coverage Determination (NCD) for Electrical Nerve Stimulators ( ) Publication Number 100-3, Manual Section Number , Benefit Category: Prosthetic Devices NCD Link: +Nerve+Stimulators (Search: Electrical Stimulators ) 7 List of local Medicare carriers is not an exhaustive list. LCD Link: (Search: Spinal Cord Stimulators ). Medicare Coverage Determinations (NCD)Medicare Coverage Determinations (NCD)66 In the case of spinal cord stimulation, Medicare has a longstanding National Coverage Determination (NCD) for electrical nerve stimulators ( ) that includes specific criteria for coverage, which are as follows: a) The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic intractable pain. b) With respect to item (a), other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient.

5 C) Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include psychological, as well as physical evaluation). d) All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment training, and follow up of the patient (including that required to satisfy item (c) must be available). e) Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. In addition to NCD criteria, some Medicare contractors may require additional SCS coverage criteria called Local Coverage Determinations (LCD)7. Please check with your local contractor. In absence of an LCD, Medicare contractors will follow the NCD. Cigna Government Services (ID) Pinnacle Business Solutions, Inc.

6 (LA, AR, MI) Palmetto GBA (NC, SC, VA, WV) Trailblazer Health Enterprises, LLC. (CO, TX, OK, NM) Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters.

7 Boston Scientific does not promote the use of its products outside their FDA-approved label. Boston Scientific Corporation Neuromodulation 25155 Rye Canyon Loop Valencia, CA 91355 Pain Management Reimbursement Call Center Phone: (866) 287-0778 Monday-Friday 6:00 am to 5:00 pm Pacific Time Fax: (877) 835-2520 NM-48611-AA Release date: March 2012 Primary diagnosis and all other applicable complications and co-morbidities (Note: Refer to published payer medical policy) Whether patient satisfies conditions for insurance coverage (Note: Refer to published payer medical policy) Treatments to date and effectiveness in addressing the patient s needs with supporting clinical information ( , History & Physical) Pharmacological information (Current and past medications, duration, and dosage) Patient s psychological suitability for the recommended treatment and whether the patient has a history of drug abuse Treatment plan (Workers Comp payers may require this document in advance) Spinal cord stimulator trial results (including percentage of pain relief or rating on a pain scale) Differentiate simple vs.

8 Complex programming by documenting time and number of changes in patient-specific program parameters5 Please ensure to document.