Pain Management Coding Alert

Published on Thu Apr 03, 2014 PDF

CMS decision could still allow you some leeway. 

The “jury” regarding payment for percutaneous lumbar decompression procedures has been back and forth for quite some time, but CMS made a decision earlier in 2014 that affects all providers focusing on these services. 

Starting point: A Jan. 14, 2014, decision memo from CMS announced that “percutaneous image guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS) is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.” The announcement did include a small silver lining, however: Medicare will cover PILD under certain conditions, outlined below.

Check Your PILD Study Protocols

The decision memo noted that CMS will cover PILD for Medicare patients when the treatment is provided in a clinical study “under section 1862(a)(1)(E) through Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved clinical study.” The study must meet several criteria, including specifying a statistical analysis and a minimum length of patient follow-up time that evaluates the beneficial effects of treatment and the duration of benefit. 

The study must analyze and answer three questions, according to CMS:

• Does PILD provide a clinically meaningful improvement of function and/or quality of life in Medicare beneficiaries compared with LSS compared to other treatments?
• Does PILD provide clinically meaningful reduction in pain in Medicare beneficiaries with LSS compared to other treatments?
• Does PILD affect the overall clinical management of LSS and decision making, including use of other medical treatments or services, compared to other treatments?

Resources: To read the entire decision and criteria for coverage, visit www.cms.gov and search for “decision memo PILD.” To learn more about PILD and its possible coding, see “Payment Update: CMS Proposes Non-Coverage of Percutaneous Image-Guided Lumbar Decompression” in Neurology and Pain Management Coding Alert, Vol. 15, Number 12.

When you’re able to report the PILD procedure, submit the Category III code 0275T (Percutaneous laminotomy/laminectomy [interlaminar approach] for decompression of neural elements, [with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy], any method, under indirect image guidance [e.g., fluoroscopic, CT], with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar).