Sacral Nerve Stimulation
A sacral nerve stimulator is a pulse generator that transmits electrical impulses to the sacral nerves through an implanted wire. These impulses cause the bladder muscles to contract, which gives the patient ability to void more properly.
Healthcare Common Procedural Coding System (HCPCS)
64590 – Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
64561 – Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement)
64581 – Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement)
64585 – Revision or removal of peripheral neurostimulator electrodes
64595 – Revision or removal of peripheral neurostimulator pulse generator or receiver
A4290 – Sacral nerve stimulation test lead, each
E0752 – Implantable neurostimulator electrodes, each
E0756 – Implantable neurostimulator pulse generator
C1767 – Generator, neurostimulator (implantable)
C1778 – Lead, neurostimulator (implantable)
C1883 – Adaptor/extension, pacing lead or neurostimulator lead (implantable)
C1897 – Lead, neurostimulator test kit (implantable)
Sacral nerve stimulation is defined as the implantation of a permanent device that modulates the neural pathways controlling bladder function. This treatment is one of several alternative modalities for patients with urge urinary incontinence whose incontinence has been refractory to behavioral and pharmacologic treatment.
This treatment involves electrical stimulation of the sacral nerves in the lower region of the spine via a totally implantable system. System components include a lead, an implantable pulse generator and an extension that connects the lead to the pulse generator. It is expected that the physician performing this service has completed a training course in the use and implantation of the device.
Sacral nerve stimulation is covered for the following indications and limitations under CMS National Coverage Determination 230.18:
Indications:
- Urinary urge incontinence.
- Urgency-frequency syndrome.
- Urinary retention.
Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation is appropriate for candidates. Both the test and the permanent implantation are covered.
Limitations:
- Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.
- Patients with stress incontinence, urinary obstruction and specific neurologic disease (e.g., diabetes with peripheral nerve involvement) that are associated with secondary manifestations of the above three indications are excluded.
- Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries.
- Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 83X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD . Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
036X
CPT/HCPCS Codes
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Note:
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Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
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64561©
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Implant neuroelectrodes
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64581©
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Implant neuroelectrodes
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64585©
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Revise/remove neuroelectrode
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A4290
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Sacral nerve stimulation test lead, each (Part B only)
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L8680
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Implt neurostim elctr each (Part B only)
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Billing Guide from BCBS
HCPCS codes:covered under the medical equipment/medical supplies and prosthetic devices benefit:
E1399: Durable medical equipment, miscellaneous (e.g. Bulk leads, needles, and cables)
E0745: Neuromuscular stimulator, electronic shock unit
CPT code:covered under the surgery benefit:
64561
HCPCS code:covered under the surgery benefit:
A4290: Sacral nerve stimulation test lead, each
2. Those patients with a positive result of the peripheral nerve stimulation test will undergo permanent implantation of the electrode and pulse generator. The following codes may be used: HCPCS codes:covered under the medical equipment/medical supplies and prosthetic devices benefit:
L8681: Patient programmer (external) for use with implantable programmable neurostimulator pulse generator
HCPCS codes:covered under the surgery benefit:
L8680: Implantable neurostimulator electrode, each
L8685: Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
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 CPT code:(there are separate CPT codes for the electrodes and the stimulator), covered under the surgery benefit 64581, 64590
3. Some patients will require analysis and reprogramming of the device once implanted. The following CPT codes may be used:
CPT codes: covered under the diagnostic imaging/lab and machine tests benefit: 95970, 95972, 95973
ICD-9-CM Codes that Support Medical Necessity
HCPCS codes:covered under the medical equipment/medical supplies and prosthetic devices benefit:
E1399: Durable medical equipment, miscellaneous (e.g. Bulk leads, needles, and cables)
E0745: Neuromuscular stimulator, electronic shock unit
CPT code:covered under the surgery benefit:
64561
HCPCS code:covered under the surgery benefit:
A4290: Sacral nerve stimulation test lead, each
2. Those patients with a positive result of the peripheral nerve stimulation test will undergo permanent implantation of the electrode and pulse generator. The following codes may be used: HCPCS codes:covered under the medical equipment/medical supplies and prosthetic devices benefit:
L8681: Patient programmer (external) for use with implantable programmable neurostimulator pulse generator
HCPCS codes:covered under the surgery benefit:
L8680: Implantable neurostimulator electrode, each
L8685: Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
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 CPT code:(there are separate CPT codes for the electrodes and the stimulator), covered under the surgery benefit 64581, 64590
3. Some patients will require analysis and reprogramming of the device once implanted. The following CPT codes may be used:
CPT codes: covered under the diagnostic imaging/lab and machine tests benefit: 95970, 95972, 95973
ICD-9-CM Codes that Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Payment is as follows:
• Hospital outpatient departments – OPPS
• Critical access hospital (CAH) – Reasonable cost
• Comprehensive outpatient rehabilitation facility – Medicare physician fee schedule (MPFS)
• Rural health clinics/federally qualified health centers (RHCs/FQHCs) – All inclusive rate, professional component only. The technical component is outside the scope of the RHC/FQHC benefit. Therefore, the provider of that technical service bills theirMedicare using the ASC X12 837 professional claim format or Form CMS-1500 and payment is made under the MPFS. For provider-based RHCs/FQHCs payment for the technical component is made as indicated above based on the type of provider the RHC/FQHC is based with.
Payment is as follows:
• Hospital outpatient departments – OPPS
• Critical access hospital (CAH) – Reasonable cost
• Comprehensive outpatient rehabilitation facility – Medicare physician fee schedule (MPFS)
• Rural health clinics/federally qualified health centers (RHCs/FQHCs) – All inclusive rate, professional component only. The technical component is outside the scope of the RHC/FQHC benefit. Therefore, the provider of that technical service bills theirMedicare using the ASC X12 837 professional claim format or Form CMS-1500 and payment is made under the MPFS. For provider-based RHCs/FQHCs payment for the technical component is made as indicated above based on the type of provider the RHC/FQHC is based with.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 64561, 64581 and A4290:
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596.52
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Low bladder compliance
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596.55
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Detrusor sphincter dyssynergia
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788.20–788.21
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Retention of urine
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788.29
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Other specified retention of urine
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788.30–788.33
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Urinary incontinence
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788.41
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Urinary frequency
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788.64
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Urinary hesitancy
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788.91
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Functional urinary incontinence
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788.99
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Other symptoms involving urinary system
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Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Note: CPT/HCPCS codes L8680 and 64585 are used for various other services. Medicare is not establishing limited coverage for these codes at this time.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Documentation must include objective evidence supporting a covered indication and objective evidence that the nationally prescribed indications and limitations are met. Such documentation should include the conservative measure used, the length of time it was tried, and any other information to support coverage.
Utilization Guidelines
This treatment is one of several alternative modalities for patients with urge urinary incontinence who have not responded to more conservative treatment for at least six months.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
Payment Requirements for Test Procedures (HCPCS Codes 64585, 64590 and 64595)
Deductible and coinsurance apply.
Payment Requirements for Device Codes A4290, E0752 and E0756
Payment is made on a reasonable cost basis when these devices are implanted in a CAH.
Payment Requirements for Codes C1767, C1778, C1883 and C1897
Only hospital outpatient departments report these codes. Payment is made under OPPS.