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Potential Genicular nerve & Si Joint Ablation Codes in 2020

dwaldman

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In the 2019 OPPS/ASC final rule, it appears CMS published a comment from someone who states they are aware of the planned creation of CPT codes for radiofrequency ablation of genicular nerves and SI joint in 2020
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https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24243.pdf


Summary of Comment Page 321-322
The commenter also recommended that CMS develop two new HCPCS G-codes to describe the performance of radiofrequency nerve ablation procedures. The commenter suggested that one of the G-codes could be created to describe procedures involving the genicular nerve, and the other G-code could be created to describe procedures involving the sacroiliac joint. The commenter further recommended that both of these G-codes be created to describe procedures describing non-opioid treatment alternatives for chronic pain management, and to assign both of these newly created G-codes to Level 2 Nerve Procedures APC 5232 based on its recommended three-level APC structure, with an estimated payment rate of $2,431. The commenter was aware that Category I CPT codes are in development, but will not be ready for release until CY 2020 at the earliest.

Summary of Response
With regard to the request to establish new HCPCS G-codes, although new CPT codes are in development for release for the CY 2020 update, we note that it does not appear that a request for new temporary Category III codes was made for CY 2019. Nonetheless, we intend to take the commenter’s request for new HCPCS G-codes under advisement.





Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs

17. Nerve Procedures and Services (APCs 5431 through 5432)

Comment: One commenter suggested that CMS restructure the two-level Nerve Procedure APCs (APCs 5431 and 5432) to provide more payment granularity for the types of procedures included in the APCs by creating a third level. The commenter believed that there is a substantial payment differential between the procedures assigned to Level 1 Nerve Procedures APC 5431 and Level 2 Nerve Procedures APC 5432, and that the current payment for some of these procedures does not adequately cover the cost of providing the services. The commenter further stated that, as an example, the procedures described by CPT codes 64633 (Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint) and 64635 (destruction by neurolytic agent paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint), which are assigned to APC 5431 with a proposed payment rate of approximately $1,644, while the geometric means for each of the procedures described by CPT codes 64633 and 64635 are $1,482 and $1,729, respectively. The commenter recommended a potential geometric mean cost for a potential three-level APC structure within the Nerve Procedures APCs and submitted a three-level APC structure, along with estimated payment rates, which is shown in the table below.
The commenter also recommended that CMS develop two new HCPCS G-codes to describe the performance of radiofrequency nerve ablation procedures. The commenter suggested that one of the G-codes could be created to describe procedures involving the genicular nerve, and the other G-code could be created to describe procedures involving the sacroiliac joint. The commenter further recommended that both of these G-codes be created to describe procedures describing non-opioid treatment alternatives for chronic pain management, and to assign both of these newly created G-codes to Level 2 Nerve Procedures APC 5232 based on its recommended three-level APC structure, with an estimated payment rate of $2,431. The commenter was aware that Category I CPT codes are in development, but will not be ready for release until CY 2020 at the earliest. Therefore, the commenter requested that CMS create such G-codes in order to allow for physicians and hospitals to report the performance of the procedures and use of the approach, and to be paid for utilization of these procedures in the interim. The commenter supplied a suggested descriptor for the G-code for the genicular nerve as: Radiofrequency nerve ablation; genicular nerves, including imaging guidance, when performed. The commenter also supplied a suggested descriptor for the APC Level Number of Singles Used to Calculate APC Geometric Mean Total Frequency of Claims APC Geometric Mean Cost Estimated Payment Rate Number of HCPCS Codes 2 Times Rule Violation 5431 113,284 116,158 $1,583 $1,555 15 0 5432 15,035 17,051 $2,476 $2,431 58 0 5433 1,757 1,763 $5,373 $5,276 28 0 G-code for the sacroiliac joint as: Radiofrequency never ablation; sacroiliac joint, including imaging guidance, when performed. Response: We appreciate the commenter’s suggestions. However, at this time, we believe that the current two-level structure Nerve Procedures APCs provide an appropriate distinction between the resource costs at each level and clinical homogeneity. We will continue to review the APCs’ structure to determine if additional granularity is necessary for this APC family in future rulemaking. In addition, we believe that more analysis of such groupings is necessary before adopting such change. With regard to the request to establish new HCPCS G-codes, although new CPT codes are in development for release for the CY 2020 update, we note that it does not appear that a request for new temporary Category III codes was made for CY 2019. Nonetheless, we intend to take the commenter’s request for new HCPCS G-codes under advisement. Therefore, after consideration of the public comment received, we are finalizing our CY 2019 Nerve Procedures APCs two-level structure, as proposed. We refer readers to Addendum A to this final rule with comment period for the complete list of APCs and their payment rates. In addition, we refer readers to Addendum B to this final rule with comment period for the payment rates for all codes reported under the OPPS. Both Addendum A and Addendum B are available via the Internet on the CMS website.
 
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