ABBOTT CODING GUIDE...2018/01/01 · References & Brief Summary INTRO SPINAL CORD STIMULATION (SCS)...

References & Brief Summary

INTRO SPINAL CORD STIMULATION (SCS) RADIOFREQUENCY ABLATION (RFA)

ABBOTT CODING GUIDE CHRONIC PAIN Effective January 1, 2018



CHRONIC PAINEffective January 1, 2018

Introduction The Chronic Pain Coding Guide is intended to provide refer-ence material related to general guidelines for reimburse-ment when used consistently with the product’s labeling. This guide includes information regarding coverage, coding and re-imbursement.

Reimbursement Hotline In addition, Abbott offers a reimbursement hotline, which pro-vides live coding and reimbursement information from dedi-cated reimbursement specialists. Coding and reimbursement support is available from 8 a.m. to 5 p.m. Central Time, Mon-day through Friday at (855) 569-6430 or [email protected]. This guide and all supporting documents are available https://www.sjm.com/en/professionals/resources-and-reimbursement. Coding and reimbursement assistance is provided subject to the disclaimers set forth in this guide.

Disclaimer This document and the information contained herein is for gen-eral information purposes only and is not intended and does not constitute legal, reimbursement, coding, business or other advice. Furthermore, it is not intended to increase or maximize payment by any payer. Nothing in this document should be construed as a guarantee by Abbott regarding levels of reimbursement, payment or charge, or that reimbursement or other payment will be re-ceived. Similarly, nothing in this document should be viewed as in-structions for selecting any particular code. The ultimate respon-sibility for coding and obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and veracity of all coding and claims submitted to third-party pay-ers. Also note that the information presented herein represents only one of many potential scenarios, based on the assumptions, variables and data presented. In addition, the customer should note that laws, regulations, coverage and coding policies are com-plex and updated frequently. Therefore, the customer should check with their local carriers or intermediaries often and should consult with legal counsel or a financial, coding or reimbursement specialist for any coding, reimbursement or billing questions or re-lated issues. This information is for reference purposes only. It is not provided or authorized for marketing use.

https://www.sjm.com/en/professionals/resources-and-reimbursementhttps://www.sjm.com/en/professionals/resources-and-reimbursementhttps://www.sjm.com/en/professionals/resources-and-reimbursement


ABBOTT CODING GUIDE SPINAL CORD STIMULATION (SCS) Effective January 1, 2018

PHYSICIAN CODING HOSPITAL OUTPATIENT ASC HOSPITAL INPATIENT ADDITIONAL CODES


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CPT™

CODE2DESCRIPTION WORK

RVUNATIONAL MEDICARE RATE

FACILITY NON FACILITYTRIAL PROCEDURE

63650 Percutaneous implantation of neurostimulator electrode array, epidural 7.15 $426 $1,353

PERMANENT PROCEDURES

63650 Percutaneous implantation of neurostimulator electrode array, epidural 7.15 $426 $1,353

63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle,epidural 10.92 $866 NA

63685Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling (Do not report 63685) in conjunction with 63688 for the same pulse generator or receiver)

5.19 $377 NA

REVISION AND REMOVAL PROCEDURES

63661 Removal of spinal neurostimulator electrode percutaneous array(s), includingfluoroscopy when performed 5.08 $336 $602

63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed vialaminotomy or laminectomy, including fluoroscopy, when performed 11.00 $876 NA

63663 Revision including replacement, when performed, of spinal neurostimulatorelectrode percutaneous array(s), including fluoroscopy, when performed 7.75 $467 $809

Physician1

Effective Dates: January 1, 2018 - December 31, 2018It is incumbent upon the physician to determine which, if any modifiers should be used first. A list of CPT™ code modifiers can be found at http://professional.sjm.com/resources

CODING AND REIMBURSEMENT FOR SPINAL CORD STIMULATION (SCS)

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Physician1


CPT™



FACILITY NON FACILITYREVISIONS AND REMOVAL PROCEDURES (CONTINUED)

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

11.52 $912 NA

63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 5.30 $387 NA

ELECTRONIC ANALYSIS AND DEVICE PROGRAMMING

95970*

Electronic analysis of implanted neurostimulator pulse generator system (e.g., 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 (i.e., cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without programming

0.45 $25 $71

* A physician or an auxiliary person employed by and under the direct supervision of that physician may provide, with or without the support of the manufacturer's representative, analysis and programming of a patient'smedical product or device "incident to" the physician's other services performed in the office setting. A patient or his payer should not be billed for analysis and programming services performed at the direction of the physician by a manufacturer's representative. Contact your MAC or other payer for any questions regarding coverage, coding and payment.


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It is incumbent upon the physician to determine which, if any modifiers should be used first. A list of CPT™ code modifiers can be found at http://professional.sjm.com/resources

Physician1

Effective Dates: January 1, 2018 - December 31, 2018

CPT™



FACILITY NON FACILITYELECTRONIC ANALYSIS AND DEVICE PROGRAMMING (CONTINUED)

95971*

Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude, pulse duration, configuration of wave form , battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measure-ments); simple spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuro-muscular) neurostimulator pulse generator/transmitter, with intraoperative or subse-quent programming; includes three or fewer parameters

0.78 $42 $52

95972*

Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measure-ment); complex spinal cord, or with intraopertive subsequent programming; includes four or more parameters

0.80 $43 $60


* A physician or an auxiliary person employed by and under the direct supervision of that physician may provide, with or without the support of the manufacturer's representative, analysis and programming of a patient'smedical product or device "incident to" the physician's other services performed in the office setting. A patient or his payer should not be billed for analysis and programming services performed at the direction of the physician by a manufacturer's representative. Contact your MAC or other payer for any questions regarding coverage, coding and payment.


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Hospital Outpatient3

CPT™ CODE2 DESCRIPTION

STATUS INDICATOR APC

NATIONAL MEDICARE RATE

TRIAL PROCEDURE

63650 Percutaneous implantation of neurostimulator electrode array, epidural J1 5462 $6,055


63650 Percutaneous implantation of neurostimulator electrode array, epidural J1 5462 $6,055

63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural J1 5463 $18,368

63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, director inductive coupling J1 5464 $27,890

J1 = Hospital Part B services paid through a comprehensive APC











IMPLANTABLE PULSE GENERATOR (IPG) AND PROGRAMMINGª

95970*

Electronic analysis of implanted neurostimulator pulse generator system (e.g., 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 (i.e., cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without programming

Q1 5734 $105

95971*

Electronic analysis of implanted neurostimulator pulse generator system (e.g., 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 (i.e., peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming; includes three or fewer parameters

S 5742 $115

95972*

Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming; includes four or more parameters

S 5742 $115

Q1 = Packaged APC payment if billed on same date of service as HCPCS assigned status indicator S, T, V or XS = Procedure or service, not discounted when multiple



* A physician or an auxiliary person employed by and under the direct supervision of that physician may provide, with or without the support of the manufacturer's representative, analysis and programming of a patient's medicalproduct or device "incident to" the physician's other services performed in the office setting. A patient or his payer should not be billed for analysis and programming services performed at the direction of the physician by a manufacturer's representative. Contact your MAC or other payer for any questions regarding coverage, coding and payment.

aParameters include: 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), more than one clinical feature (e.g., rigidity, dyskinesia, tremor).










63661 Removal of spinal neurostimulator electrode percutaneous array(s), includingfluoroscopy, when performed Q2 5431 $1,610

63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy orlaminectomy, including fluoroscopy, when performed Q2 5461 $2,879

63663 Revision including replacement, when performed, of spinal neurostimulator electrodepercutaneous array(s), including fluoroscopy, when performed J1 5462 $6,055

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

J1 5463 $18,368

63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver Q2 5461 $2,879

J1 = Hospital Part B services paid through a comprehensive APCQ2 = T-packaged codes




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Ambulatory Surgery Center4 (ASC)



PAYMENT INDICATOR

MULTI-PROCEDUREDISCOUNT


TRIAL PROCEDURE

63650 Percutaneous implantation of neurostimulator electrode array,epidural J8 N $4,595


63650 Percutaneous implantation of neurostimulator electrode array,epidural J8 N $4,595

63655 Laminectomy implant of neurostimulator electrodes, plate/paddle, epidural J8 N $15,006

63685

Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling (Do not report 63685 in conjunction with 63688 for the same pulse generator or receiver)

J8 N $22,892

J8 = Device-intensive procedure; paid at adjusted rate.



PAGE 1 PAGE 2





PAYMENTINDICATOR

MULTI-PROCEDURE RATE



63661 Removal of spinal neurostimulator electrode percutaneousarray(s), including fluoroscopy, when performed G2 N $786

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

G2 N $1,500

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

J8 N $3,101

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

J8 N $12,915

63688 Revision or removal of implanted spinal neurostimulator pulsegenerator or receiver A2 N $1,500


A2 = Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.G2 = Non office-based surgical procedure added in CY2008 or later; payment base on OPPS relative payment rate.J8 = Device-intensive procedure; paid at adjusted rate.



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Hospital Inpatient5

Effective Dates: October 1, 2017 - September 30, 2018


PROCEDUREPOSSIBLE

ICD-10 PCS CODE

DESCRIPTION

LEAD INSERTION

00HU0MZ Insertion of neurostimulator lead into spinal canal, open approach

00HU3MZ Insertion of neurostimulator lead into spinal canal, percutaneous approach

00HV0MZ Insertion of neurostimulator lead into spinal cord, open approach

00HV3MZ Insertion of neurostimulator lead into spinal cord, percutaneous approach

LEAD REMOVAL

00PU0MZ Removal of neurostimulator lead from spinal canal, open approach

00PU3MZ Removal of neurostimulator lead from spinal canal, percutaneous approach

00PV0MZ Removal of neurostimulator lead from spinal cord, open approach

00PV3MZ Removal of neurostimulator lead from spinal cord, percutaneous approach

LEAD REVISION

00WU0MZ Revision of neurostimulator lead in spinal canal, open approach

00WU3MZ Revision of neurostimulator lead in spinal canal, percutaneous approach

00WVOMZ Revision of neurostimulator lead in spinal cord, open approach

00WV3MZ Revision of neurostimulator lead in spinal cord, percutaneous approach

LEAD REPLACEMENT

Two codes are required to identify a device replacement; one code for the removal of the existing device and one code for the implantation of a new device





Hospital Inpatient5



PROCEDUREPOSSIBLE

ICD-10 PCS CODE

DESCRIPTION

GENERATOR IMPLANT

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

0JH63BZ Insertion of single array stimulator generator into chest subcutaneous tissue and fascia, percutaneousapproach

0JH70BZ Insertion of single array stimulator generator into back subcutaneous tissue and fascia, open approach

07H73BZ Insertion of single array stimulator generator into back subcutaneous tissue and fascia, percutaneousapproach

0JH80BZ Insertion of single array stimulator generator into abdomen subcutaneous tissue and fascia, open approach

0JH83BZ Insertion of single array stimulator generator into abdomen subcutaneous tissue and fascia, percutaneousapproach

GENERATOR REMOVAL

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

GENERATOR REVISION

0JWT0MZ Revision of stimulator generator from trunk subcutaneous tissue and fascia, open approach

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

GENERATOR REPLACEMENT

Two codes are required to identify a device replacement: one code for the removal of the existing device and one code for the implantation of a new device.





Hospital Inpatient5



PROCEDURE SCENARIO TYPICAL MS-DRG ASSIGNMENT MS-DRG TITLENATIONAL

MEDICARE RATE

Implant or replace SCS system; generator and lead(s)

Pain disorder or due to causalgia or RSD, and other nervous system disorders

028 Spinal procedures with MCC $33,507

029 Spinal procedures with CC or spinal neurostimulators $19,735

Pain due to musculoskeletal disorders 518

Back and neck procedure except spinal fusion with MCC or disc device/neurostim $17,437

Implant or replace generator only


040 Peripheral/cranial nerve and other nervous system procedure with MCC $22,960

041Peripheral/cranial nerve and other nervous system procedure with CC or peripheral neurostim

$14,051

042 Peripheral/cranial nerve and other nervous system procedure without CC/ MCC $11,511

Pain due to musculoskeletal disorders

981 Extensive O.R. procedure unrelated to prin-cipal diagnosis with MCC $25,985

982 Extensive O.R. procedure unrelated to prin-cipal diagnosis with CC $14,971

983 Extensive O.R. procedure unrelated to prin-cipal diagnosis without CC/ MCC $9,918





Hospital Inpatient5



PROCEDURE SCENARIO TYPICAL MS-DRG ASSIGNMENT MS-DRG TITLENATIONAL

MEDICARE RATE

Implant or replace lead(s) only



029 Spinal procedures with CC or spinal neurostimulators $19,735

030 Spinal procedures without CC/MCC $12,859

Pain due to musculoskeletal disorders

518 Back and neck procedure except spinal fu-sion with MCC or disc device/neurostim $17,437

519 Back and neck procedure except spinal fu-sion with CC $10,871

520 Back and neck procedure except spinal fu-sion with without CC/MCC $7,814

Remove SCS system; generator and lead(s)Remove or revise lead(s) only


029 Spinal procedures with CC or spinal neuro-stimulators $19,735

030 Spinal procedures without CC/MCC $12,859

Remove, generator onlyThese codes are not considered "significant procedures" for the purpose of MS-DRG as-signment. A non-surgical (i.e., medical) MS-DRG is assigned to the inpatient hospital ad-mission according to the principal diagnosis.


DIAGNOSISPHYSICIAN CODING HOSPITAL OUTPATIENT ASC HOSPITAL INPATIENT ADDITIONAL CODES


HCPCS 1 HCPCS 2

HCPCS Device Category C-Codes2, 7

C-CODE DESCRIPTIONC-CODES FOR MEDICARE HOSPITAL OUTPATIENT PROCEDURES

C1767 Generator

C1778 Neurostimulator lead (use for permanent procedure)

C1787 Patient programmer, neurostimulator

C1883 Adapter or extension

C1897 Lead neurostimulator test kit, pacing lead (use for trial procedures)


Additional information on C-Codes can be found at: https://www.sjm.com/~/media/galaxy/hcp/resources-reimbursement/reimbursement-support/shared/hcpcs-device-category-c-codes.pdf?la=en


https://www.sjm.com/~/media/galaxy/hcp/resources-reimbursement/reimbursement-support/shared/hcpcs-device-category-c-codes.pdf?la=en




HCPCS 1 HCPCS 2



HCPCS Device Codes2, 7 and Descriptions

C-CODE DESCRIPTIONLEAD

L8680 Implantable neurostimulator electrode, each

IMPLANTABLE PULSE GENERATOR (IPG)

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

EXTERNAL RECHARGER

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

PATIENT PROGRAMMER

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

Additional information on C-Codes can be found at: https://www.sjm.com/~/media/galaxy/hcp/resources-reimbursement/reimbursement-support/shared/hcpcs-device-category-c-codes.pdf?la=en

https://www.sjm.com/~/media/galaxy/hcp/resources-reimbursement/reimbursement-support/shared/hcpcs-device-category-c-codes.pdf?la=en




HCPCS 1 HCPCS 2

ICD-10CM Diagnosis Codes6

Diagnosis codes are used by both hospitals and physicians to document the indication for the procedure. For Spinal Cord Stimulation (SCS) patients, there are many possible diagnosis code scenarios and a wide variety of possible combinations. The possible scenarios and combinations are too numerous to capture in this document. The customer should check with their local carriers or intermediaries and should consult with legal counsel or a financial, coding or reimbursement specialist for coding, reimbursement or billing questions related to ICD-10CM diagnosis codes.




ABBOTT CODING GUIDE RADIOFREQUENCY ABLATION (RFA) Effective January 1, 2018

PHYSICIAN CODING HOSPITAL OUTPATIENT ASC ADDITIONAL CODES


OTHER BILLING REQUIREMENTS



PHYSICIAN CODING HOSPITAL OUTPATIENT ASC ADDITIONAL CODES OTHER BILLING REQUIREMENTS

CODING AND REIMBURSEMENT FOR RADIOFREQUENCY ABLATION (RFA)Physician1


CPT™



FACILITY NON FACILITYCERVICAL SPINE/THORACIC SPINE

64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imagingguidance (fluoroscopy or CT); cervical or thoracic, single facet joint 3.84 $233 $429

64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imagingguidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint 1.32 $71 $193

LUMBAR SPINE/SACRAL SPINE

64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imagingguidance (fluoroscopy or CT); lumbar or sacral, single facet joint 3.78 $229 $424

64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imagingguidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint 1.16 $62 $175

OTHER PERIPHERAL NERVES

64640 Destruction by neurolytic agent; other peripheral nerve or branch 1.23 $96 $136

77002 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection,localization device) 0.54 NA $96








CERVICAL SPINE/THORACIC SPINE

64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), withimaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint J1 5431 $1,610

64634Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint

N NA Packaged


64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), withimaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint J1 5431 $1,610

64636Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint

N NA Packaged


64640 Destruction by neurolytic agent; other peripheral nerve or branch T 5443 $672

77002 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection,localization device) N NA Packaged

J1 = Hospital Part B services paid through a comprehensive APCN = Items and services packaged into APC ratesT = Significant procedure, multiple reduction applies


CODING AND REIMBURSEMENT FOR RADIOFREQUENCY ABLATION (RFA)







PAYMENT INDICATOR

MULTI-PROCEDURE DISCOUNT


CERVICAL SPINE/THORACIC SPINE

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

G2 Y $786

64634Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint

N1 NA NA


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

G2 Y $786

64636Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint

N1 NA NA


64640 Destruction by neurolytic agent; other peripheral nerve or branch P3 Y $88

77002 Fluoroscopic guidance for needle placement (e.g., biopsy,aspiration, injection, localization device) NA NA NA

G2 = Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment rate.N1 = Package service/item; no separate payment made.P3 = Office-based surgical procedure added to ASC list in CY2008 or later with MPFS non-facility PE RVUs payment based on non-facility PE RVUs.






Diagnosis codes are used by both hospitals and physicians to document the indication for the procedure. For Radiofrequency Ablation (RFA) patients, there are many possible diagnosis code scenarios and a wide variety of possible combinations. The possible scenarios and combinations are too numerous to capture in this document. The customer should check with their local carriers or intermediaries and should consult with legal counsel or a financial, coding or reimbursement specialist for coding, reimbursement or billing questions related to ICD-10CM diagnosis codes.

ICD-10CM Diagnosis Codes6





CODING AND REIMBURSEMENT FOR RADIOFREQUENCY ABLATION (RFA)Other Billing RequirementsPre-Procedure RequirementsMost insurance providers require at least one diagnostic procedure for each treated site, with some requiring two. Please check with thepayer before performing any radiofrequency (RF) procedure to be sure you have completed all required step therapies.

AppealsThere are numerous reasons that a facility or physician may face a denied, pended or underpaid claim.

Claims are typically denied or pended for four reasons: The claims processors have made an administrative error The claim forms contain clerical errors The payer has not deemed the procedure to be medically necessary The payer’s requests for information have gone unanswered by the patient

Appealing Denied ClaimsA denied claim can be appealed. When a claim has been denied, review the Explanation of Benefits (EOB) for an explanation of the denial.

Immediately contact the payer if the EOB does not explain the reason for the denial and request an explanation. In cases where the denial was a result of a clerical error on the claim form, confirm the correct code with the payer and resubmit the corrected claim form.

Other reasons for a denied claim may include: The technology is considered investigational The CPT™ code does not meet the diagnosis code The medical necessity has not been determined

Should your claim have been denied for one of these reasons, it is best to contact the payer directly in order to offer additional information about the procedure. You should ask the claims processor to indicate which additional materials should be provided in order to potentially reverse the original coverage determination. If you feel that your claim has been underpaid, contact the claims office indicated on the patient’s EOB and request a review of your claim.

Reasons for underpayment of a procedure include but are not limited to: The coding of the procedure performed is incorrect The lack or misuse of an appropriate modifier The lack of supporting documentation

You will find that each payer has its own unique review process. It is best to contact the payer for the exact guidelines. In most cases, however, you will be asked to submit your appeal request in writing. When contacting the payer, be sure to inquire as to where the request should be sent and to whose attention it should be directed.

If you have additional reimbursement questions, please call the Reimbursement Hotline at 800-727-7846.



Abbott

One St. Jude Medical Dr., St. Paul, MN 55117 , USA , Tel: 1.651.756 .2000 SJM.comSt. Jude Medical is now Abbott.

Rx Only Brief Summary: Prior to using these devices, please review the Instructions for Use for a complete listing of indications, contraindications, warnings, precautions, potential adverse events and directions for use.

Unless otherwise noted, all marks herein are trademarks of the Abbott group of companies.

© 2017 Abbott. All Rights Reserved.

25240-SJM-HER-0917-0104(1) | Item approved for U.S. use only.

References

1.

2. CPT is a trademark of the American Medical Association

3.

4.

5. Ambulatory Surgical Center Payment-Final Rule CY2018 Payment Rates. CMS-1678-FC: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASC-Regulations-and-Notices-Items/CMS-1678-FC.html

6. American Medical Association 2018 ICD-10-CM: The Complete Official Codebook. Edition 1; 2018.

7. CMS, 2018 Alpha-Numeric Index HCPS code set: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS-Items/2018-Alpha-Numeric-HCPCS-File-.html

Hospital Outpatient Prospective Payment-Final Rule with Comment Period and Final CY2018 Payment Rates. CMS-1678-FC: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1678-FC.html

Physician Prospective Payment-Final rule with Comment Period and Final CY2018 Payment Rates. CMS-1676-F: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-F.html

Hospital Inpatient Prospective Payment-Final Rule with Comment Period and Final FY2018 Payment Rates. CMS-1677-F: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Final-Rule-Home-Page-Items/FY2018-IPPS-Final-Rule-Regulations.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Final-Rule-Home-Page-Items/FY2018-IPPS-Final-Rule-Regulations.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascendinghttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Final-Rule-Home-Page-Items/FY2018-IPPS-Final-Rule-Regulations.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascendinghttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-F.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-F.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1678-FC.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1678-FC.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASC-Regulations-and-Notices-Items/CMS-1678-FC.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASC-Regulations-and-Notices-Items/CMS-1678-FC.htmlhttps://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS-Items/2018-Alpha-Numeric-HCPCS-File-.html

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ABBOTT CODING GUIDE...2018/01/01 · References & Brief Summary INTRO SPINAL CORD STIMULATION (SCS)...

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