Spinal Cord Stimulator (SCS) System Surgical …

1 UPN Model Number Surgical EQUIPMENT / IMPLANTABLE ITEMS L-Code C-Code Description The following is a catalog of Precision implants, supplies and common accessories cross-walked to applicable HCPCS Level II codes ( , C-codes and L-codes). For Medicare outpatient hospital setting, C-codes are required for billing with applicable CPT codes, but they are not separately payable by Medicare. For most non-Medicare plans, L-codes or Revenue code 278 may be appropriate for reporting purposes. We recommend that you consult with your payer on appropriate reporting options for implantable devices and supporting accessories. Please go to for the most recent version of the crosswalk. 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.

2 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. Boston Scientific does not promote the use of its products outside their FDA-approved label. Information included herein is current as of October 1, 2011, but is subject to change without notice. Reimbursement Call Center: 866-287-0778 SC-1010B Precision Implantable Pulse Generator (IPG) & Charging Kit C1820 L8687 SC-1010C Precision Implantable Pulse Generator (IPG) & Charging Kit C1820 L8687 SC-1110-02 Precision Implantable Pulse Generator (IPG)

3 Part of C1820 L8687 SC-2158-30/50/70 Phase III Linear Lead with preloaded Enhanced Stylet - 30 cm/50cm/70 cm C1778 L8680 SC-2158-50T Phase III Trial Lead with preloaded Enhanced Stylet - 50 cm SC-2158-50E Linear Trial Lead with preloaded Stylet - 50 cm SC-2208-30/50/70 Linear ST Lead - 30cm/50 cm/70 cm SC-2208-50T Linear ST Trial Lead - 50 cm SC-2208-70T Linear ST Trial Lead - 70 cm SC-2218-30/50/70 Linear ST Lead with preloaded Enhanced Stylet - 30 cm/50 cm/70 cm SC-2218-50T Trial ST Lead with preloaded Enhanced Stylet - 50 cm SC-2218-70T Trial ST Lead with preloaded Enhanced Stylet - 70 cm SC-2218-50E/70E ST Linear Trial Lead with preloaded Stylet - 50 cm/70 cm SC-2352-50/70 Linear 3-4 Lead - 50 cm/70 cm SC-2352-50E Linear 3-4 Trial Lead 50 cm SC-2366-30/50/70 Linear 3-6 Lead 30 cm/50 cm/70 cm SC-2366-50E Linear 3-6 Trial Lead 50 cm SC-8120-50/70 Artisan 2x8 Surgical Lead - 50 cm/70 cm SC-8216-50/70 Artisan Surgical Lead with PlatnaLock Technology - 50 cm/70 cm SC-2316-50/70 Infinion Lead Kit - 1x16 - 50cm/70cm SC-2316-50E Infinion Trial Lead Kit - 1x16 - 50cm SC-3400-30 Splitter 2x8 Kit and/or 1x16 Splitter C1883 L8699 SC-3138-25/35/55 Phase III Lead Extension - 25 cm/35 cm/55 cm SC-3304-25 2x4 Splitter - D4 - 25 cm SC-3354-25 2x4 Splitter - W4 - 25cm SC-9004-35/55/70 Precision Connector M1- 35 cm/55 cm/70 cm M365SC1010B0 M365SC1010C0 M365SC1110020 M365SC2158300/500/700 M365SC215850T0 M365SC215850E0 M365SC2208300/500/700 M365SC220850T0 M365SC220870T0 M365SC2218300/500/700 M365SC221850T0 M365SC221870T0 M365SC221850E0/70E0 M365SC2352500/700 M365SC235250E0 M365SC2366300/500/700 M365SC236650E0 M365SC8120500/700 M365SC8216500/700 M365SC2316500/700 M365SC231650E0 M365SC3400300 M365SC3138250/350/550 M365SC3304250 M365SC3354250 M365SC9004350/550/700 2012 Surgical Equipment Crosswalk NM-30408-AC Release date: April 2012 2012 Boston Scientific Corporation and its affiliates.

4 All rights reserved. NeuromodulationNeuromodulation 2012 Precision Spinal cord Stimulator (SCS) System Surgical Equipment Crosswalk to HCPCS Codes Model Number SC-5500-4 Patient Programmer Kit: Remote Control, Remote Control Case C1787 L8681 SC-6412-3 Charging System Kit: Charger Base Station, AC/DC Power Supply, Charger , Charging Belt Part of C1820* L8689 SC-6500-03 Patient Trial Kit: ETS Belt; ETS Battery NA L9900 Surgical SPARES L-Code C-Code Description UPN KIT C-Code PATIENT EQUIP. UPN L-CODE Descriptor HCPCS C-CODE Descriptor HCPCS 2012 Boston Scientific Corporation and its affiliates. All rights reserved. 2012 Surgical Equipment Crosswalk NM-30408-AC HCPCS Level II Descriptors: L-Code L-Code C-Code See front page for important information about the uses and limitations of this document. SC-5312 Charger Part of C1820* L8689 SC-5305 Charger Base Station L9900 SC-6300 AC/DC Power Supply (for Charger Base Station) SC-6358-0BK/1BK/5BK Charging Belt Size S(0BK); Size M(1BK).

5 Extension(5BK) NA L9900 SC-6350 Adhesive Kit (26 adhesives) SC-5212 Remote Control (with iconic screen capabilities) C1787 L8681 BPB-3100 Remote Control Case NA L9900 C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging System C1778 Lead, neurostimulator (implantable) C1787 Patient programmer, neurostimulator C1883 Adapter/ extension, pacing lead or neurostimulator lead (implantable) L8680 Implantable neurostimulator electrode, each L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension L8689 External recharging System for battery (internal) for use with implantable neurostimulator, replacement only L8699 Prosthetic implant, not otherwise specified L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code * When used with initial SCS implanted pulse generator M365SC53120 M365SC53050 M365SC63000 M365SC63580BK0/81BK0/85BK0 M365SC63500 M365SC52120 M365 BPB31000 M365SC4100A0 M365SC42750 M365SC42760 M365SC42000 M365SC42050 M365SC42060 M365SC42100 M365SC42300 M365SC42520 M365SC42540 M365SC43000 M365SC43010 M365SC43050 M365SC43060 M365SC43100 M365SC43110 M365SC4316 M365SC43200 M365SC43500 M365SC43650 M365SC4385300/500/700 M365SC4395300/500/700 M365SC44000 SC-4100A Cable NA SC-4275 Hex Wrench SC-4276 Hex Wrench 3 SC-4200 Insertion Needle SC-4205 Insertion Needle 5 SC-4206 Insertion Needle SC-4210 Epimed Curved Needle SC-4230 Passing Elevator SC-4252 Straw Tunneling Tool (28 cm) SC-4254 Long Tunneling Tool (35 cm) SC-4300 1 cm Suture Sleeve (set of 1)

6 SC-4301 1 cm Split Suture Sleeve (set of 1) SC-4305 cm Suture Sleeve (set of 2) SC-4306 cm Split Suture Sleeve (set of 1) SC-4310 4 cm Suture Sleeve (set of 1) SC-4311 4 cm Split Suture Sleeve (set of 1) SC-4316 Clik Anchor (Set of 2) C1883 L8699 SC-4320 Med - A ( Surgical Medical Adhesive) NA L9900 SC-4350 Lead Blanks SC-4365 Introducer Kit SC-4385-30/50/70 Stylet Kit w/steering cap - 30 cm/50 cm/70 cm SC-4395-30/50/70 Stylet Kit w/steering cap & stiffer stylet - 30 cm/50 cm/70 cm SC-4400 IPG Port Plug L9900 M365SC550040 M365SC641230 M365SC6500030 UPN Release date: April 2012 Model Number Description Description Model Number