Description
The review shall identify claims billed incorrectly as percutaneous implantation of neurostimulator electrode arrays when the medical record demonstrates the transcutaneous placement of a device.
Affected Code(s)
64553, 64555, 95971, 95972
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare National Coverage Determination Manual, Chapter 1, Part 1, §30.3- Acupuncture
8. Medicare National Coverage Determination Manual, Chapter 1, Part 2, §160.7.1(B)- Assessing Patients Suitability for Electrical Nerve Stimulation Therapy
9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
10. Noridian Healthcare Solutions, LLC Local Coverage Determination (LCD) L34328 Peripheral Nerve Stimulation Original Effective Date: 10/01/2015, Revised 12/01/2019
11. Noridian Healthcare Solutions, LLC LCD L37360 Peripheral Nerve Stimulation Original Effective Date: 08/27/2018; Revised 12/01/19
12. Noridian Healthcare Solutions, LLC LCA A55530 Billing and Coding Peripheral Nerve Stimulation (JE) Original Effective Date: 8/27/2018, Revised 01/01/2023
13. Noridian Healthcare Solutions, LLC LCA A55531 Billing and Coding: Peripheral Nerve Stimulation (JF) Original Effective Date: 8/27/2018, Revised 01/01/2023
14. Wisconsin Physicians Service Insurance Corporation Local Coverage Article (LCA) A56062 Billing and Coding: Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT), Original Effective Date: 8/01/2018, Revised 05/26/2022, Retired 01/26/2023
15. First Coast Service Options, Inc LCA A54794 Percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT) Original Effective Date: 12/24/2015, retired 01/01/22
16. AMA CPT Codebook