Wiki Medical Necessity ICD-9 Codes that support Spinal Cord Stimulators

[chasidyh@hotmail.com]

Our office is located in TN and I have a denial for Medicare for a spinal cord stimulator due to lack of medical necessity. Anyone out there have any codes that support medical necessity for spinal cord stimulators?

 

[mitchellde]

you will need to use the dx code for the diagnosis the provider has documented. It may be that you used an unspecified code, many payers have started denying claims with unspecified dx codes using the reason lack of medical necessity.

 

[twizzle]

Our office is located in TN and I have a denial for Medicare for a spinal cord stimulator due to lack of medical necessity. Anyone out there have any codes that support medical necessity for spinal cord stimulators?

Generally, these devices are placed because of pain. You would assign pain, whether chronic pain syndrome(338.4) or chronic pain(338.29) or whatever, and the reason the patient has pain as the secondary diagnosis. This is usually degenerative disc disease or something along those lines. Either way, pain is the reason for the encounter, not disc disease which will probably be denied.
Hope this helps.

 

[mitchellde]

Generally, these devices are placed because of pain. You would assign pain, whether chronic pain syndrome(338.4) or chronic pain(338.29) or whatever, and the reason the patient has pain as the secondary diagnosis. This is usually degenerative disc disease or something along those lines. Either way, pain is the reason for the encounter, not disc disease which will probably be denied.
Hope this helps.

I agree however the provider must document chronic pain syndrome, or even chronic pain, it cannot be inferred by the length of time the patient has been in pain or the degree of pain. It is truely documentation driven, so the question is what does the provider state in the note as the need for the treatment.

 

[dwaldman]

I agree with above posts you received. If you are looking for a list of ICD-9s to review check the below

http://professional.medtronic.com/pt/neuro/scs/rm-pm/index.htm#.UVK6jSIo6P8

Above click on the coding and coverage PDF, which describes commonly used codes.

Below in the procedure documentation guide PDF there are examples of states who have LCD which would potentially have a list a "ICD-9-CM that meet medical necessity"

http://www.controlyourpain.com/professionals/reimbursement/physician.cfm

In addition to NCD criteria, some Medicare contractors may require additional SCS coverage criteria called Local Coverage Determinations (LCD)7. Please check with your local contractor. In absence of an LCD, Medicare contractors will follow the NCD.

Cigna Government Services (ID)
www.cgsmedicare.com

Pinnacle Business Solutions, Inc. (LA, AR, MI)
www.pinnaclemedicare.com

Palmetto GBA (NC, SC, VA, WV)
www.palmettogba.com

Trailblazer Health Enterprises, LLC. (CO, TX, OK, NM)

www.trailblazerhealth.com

 

[dwaldman]

Attached is the NCD to also review for your appeal to demonstrate criteria was actually met and that it was denied in error.

http://www.cms.gov/medicare-coverag...DId=240&ncdver=1&DocID=160.7&bc=gAAAABAAAAAA&

B - Central Nervous System Stimulators (Dorsal Column and Depth Brain Stimulators)

The implantation of central nervous system stimulators may be covered as therapies for the relief of chronic intractable pain, subject to the following conditions:

1 - Types of Implantations

There are two types of implantations covered by this instruction:

•Dorsal Column (Spinal Cord) Neurostimulation - The surgical implantation of neurostimulator electrodes within the dura mater (endodural) or the percutaneous insertion of electrodes in the epidural space is covered.


•Depth Brain Neurostimulation - The stereotactic implantation of electrodes in the deep brain (e.g., thalamus and periaqueductal gray matter) is covered.
2 - Conditions for Coverage

No payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the conditions listed below have been met:

•The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic intractable pain;


•With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient;


•Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include psychological, as well as physical evaluation);


•All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment training, and followup of the patient (including that required to satisfy item c) must be available; and


•Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation.