Part B Insider (Multispecialty) Coding Alert

Published on Mon Feb 03, 2014 PDF

Plus: Learn about new treatment options for uncontrolled seizures.

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).

Watch for New Seizure Treatment Options

The Food and Drug Administration (FDA) has approved two new therapies for partial-onset seizures that your neurologists and patients might consider for some situations. Both therapies target patients with refractory epilepsy who cannot be helped by resection surgery (345.x1, Epilepsy and recurrent seizures … with intractable epilepsy).

One therapy involves an implantable device that can identify brain activity and instantly respond to seizure activity as it happens.

“Within a second or two [the device can] deliver brief stimuli to the brain near the seizure focus that will possibly alter or prevent a seizure from evolving further into a disabling seizure that otherwise would last many seconds,” Gregory Bergey, MD, professor of neurology and director of the Johns Hopkins Epilepsy Center (JHEC), stated in a Neurology Today article. JHEC was one of 32 sites where the NeuroPace system was tested.

Two years after studies began, there’s been “a 50 percent reduction in seizures in more than 50 percent of patients,” said Robert E. Gross, MD, PhD, professor of neurology at Emory University in Atlanta.

The other new therapy is an antiepileptic drug (AED) that is chemically related to some medications already on the market (carbamazepine, used to treat epilepsy or trigeminal neuralgia, and oxcarbazepine, used to treat seizures) but that researchers believe might cause fewer side effects. The new medication, eslicarbazepine acetate, will be marketed in the U.S. under the brand name Aptiom, and is already in use in Europe. The medication will only be available in tablet form, which means the neurologist will prescribe the medication to patients but will not administer the drug in an office setting. That means you won’t have any charges associated with the new medication other than the E/M code for the office visit.