Medical Coding and Billing Guidelines.
Please see the Coding of Peripheral Nerve Stem leads according to scenarios modifiers will be changed, below it is explained. While talking about the state Arkansas, and Sprint Peripheral Nerve Stem, the doctors will get $10,100 which is correct because as per adjusted rate calculation for a Arkansas ‘dual kit’ will get reimbursed from Medicare worth $ 10,655.3 in ASC setting.
Peripheral Nerve Stem Fee Schedule
There are 09 different payment rates available for Arkansas according to counties, which can be confirmed by calling Medicare. For detailed idea of ASC FS, you can consult with a seasoned medial biller and coder who can give you further understanding to establish which amount exactly covers which area.
For PNSt coding consult below information and tables. It covers coding for office, ASC and outpatient setting.
CPT CODE: 64555 (Percutaneous Implantation of, Neurostimulator Electrode Array; Peripheral Nerve (excludes sacral nerve)
POS: 24
Global Surgical Period: 10 Days
Single Sprint Lead Implant Procedure
Medicare National and Arkansas Wage Index Adjusted Price
Dual Sprint Lead Implant Procedure
Medicare National and Arkansas Wage Index Adjusted Price
Note: According to ASC Fee Schedule for Arkansas single lead will yield $5327.65 while dual lead will yield $ 10,655.30
Additional Procedures:
Additional procedures such as ultrasound guidance (CPT 76942), fluoroscopic guidance (CPT 77002), and electronic analysis/programming (CPT 95970, 95971, 95972) may be performed and are packaged into the payment of the PNS lead implant procedure, and not eligible for separate payment in the ASC. Appropriate use of additional procedures will vary based on the patient condition and clinical documentation.
OFFICE: CODING & BILLING FOR PNS SYSTEM
Cpt code: 64555 (percutaneous implantation of, neuro-stimulator electrode array; peripheral nerve (excludes sacral nerve)
POS: 11
Global Surgical Period: 10 Days
Single Sprint Lead Implant Procedure
Medicare National and Arkansas Wage Index Adjusted Price
Dual Sprint Lead Implant Procedure
Medicare National and Arkansas Wage Index Adjusted Price
HOPD: CODING & BILLING FOR PNS SYSTEM
Cpt code: 64555 (percutaneous implantation of, neuro-stimulator electrode array; peripheral nerve (excludes sacral nerve)
POS: 11
Global Surgical Period: 10 Days
Single Sprint Lead Implant Procedure
Medicare National and Arkansas Wage Index Adjusted Price
Medicare provides reimbursement to Hospital Outpatient Departments (HOPDs) through the Ambulatory Payment Classification (APC) system, where each Current Procedural Terminology (CPT) code is categorized into an APC group with an associated payment rate. Commercial or private payers may utilize Medicare rates or their own contracted rates for reimbursement.
In the Hospital Outpatient Department, Medicare designates CPT 64555 with status indicator J1, indicating that hospital Part B services are encompassed within a comprehensive APC (C-APC). Consequently, Medicare reimburses the facility a unified C-APC rate for each date of service, with all covered services bundled into this single payment.
Hospitals must include Healthcare Common Procedure Coding System (HCPCS) Level II codes and their corresponding charges on claims. Although there’s no distinct reimbursement for these codes, Medicare uses them in future rate-setting. Commercial or private payers may also employ HCPCS codes and potentially reimburse separately based on their contractual agreement with the Hospital Outpatient Department (HOPD).
Get consultation to know which insurance utilize what code.
Modifiers:
A modifier is added to a CPT code to signify that the service or procedure performed has been modified due to a particular circumstance without altering its definition or code. Guidelines from payers regarding modifier usage differ depending on the payer and plan type, and it’s essential to verify them before submitting a claim. For instance, in a scenario where a Medicare Advantage plan processes the claim through a Commercial or Private payer, they may utilize either Medicare modifiers or their own set of modifiers.
Examples of Coding Two-Lead Implant Procedure: Same Nerve or Different Nerves or Bilateral Nerves – Same Session
Medicare:
64555
64555-XS
Commercial / Non-Medicare
64555
64555-59
Example A: In one procedure, the physician implants a PNS lead to target the sciatic nerve percutaneously. Subsequently, another PNS lead is implanted targeting the same sciatic nerve.
Example B: A PNS lead is percutaneously implanted by the physician to target the suprascapular nerve. During the same procedure, a second PNS lead is implanted targeting the axillary nerve.
Example C: During a single session, the physician implants a PNS lead targeting the left medial branch at L3, followed by the implantation of a second PNS lead targeting the right medial branch at L3.
Examples of Coding Discontinued Procedure:
Medicare and Commercial / Non-Medicare
64555
64555-73
Medicare and Commercial / Non-Medicare
64555
64555-74
Example: Following standard surgical preparation, the PNS System was readied for implantation in a sterile environment. Before anesthesia (local, regional, or general) and lead implantation, the physician detected an irregular heart rhythm, prompting the decision to halt the PNS lead implantation and direct the patient to a specialist.
Example: After customary surgical preparation, the PNS System was prepared for implantation in a sterile setting. Anesthesia (local, regional, or general) was administered, and during the PNS lead placement procedure, the patient exhibited an irregular heart rhythm. The physician opted to cease PNS lead implantation and arranged for the patient to receive specialist care.
Examples of Coding Repeat Procedure: Same Day or Within the 10-Day Global Period
Medicare and Commercial / Non-Medicare
64555
64555-76
Example A: After implanting a PNS lead to target the median nerve, the lead was accidentally removed while the patient was changing clothes. The physician promptly replaced the lead later that day.
Example B: Following the implantation of a PNS lead targeting the occipital nerve at C2, the lead was unintentionally withdrawn during a dressing change on the eighth day after surgery. Within the 10-day global period, the physician performed a repeat procedure to replace the lead on the ninth post-operative day.
