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63663 | Revise spine eltrd perq aray | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
63661 | Remove spine eltrd perq aray | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
63688 | Rev/rmv imp sp npg/r dtch cn | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
L8688 | Implt nrostm pls gen dua non | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
63662 | Remove spine eltrd plate | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
63655 | PR LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
63650 | PR PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
95970 | PR ELEC ALYS IMPLT NPGT PHYS/QHP W/O PROGRAMMING | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
63664 | Revise spine eltrd plate | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
L8686 | Implt nrostm pls gen sng non | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
L8680 | KIT NRSTM 40CM STIMLOC . | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
95971 | PR ELEC ALYS IMPLT NPGT SMPL SP/PN NPGT PRGRMG | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
L8687 | KIT NEUROSTIMULATOR SENZA IPG STERILE LATEX FREE DISPOSABLE | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
1999 | ANESTHESIOLOGY GROUP | CPT | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
95973 | Analyze neurostim complex | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
L8685 | Implt nrostm pls gen sng rec | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
63685 | PR INSJ/RPLCMT SPINAL NPG/RCVR POCKET CRTJ&CONNJ | HCPCS | Last accessed November, 2011. |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. |
63663 | Revise spine eltrd perq aray | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
63661 | Remove spine eltrd perq aray | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
63688 | Rev/rmv imp sp npg/r dtch cn | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
L8688 | Implt nrostm pls gen dua non | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
63662 | Remove spine eltrd plate | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
63655 | PR LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
63650 | PR PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
95970 | PR ELEC ALYS IMPLT NPGT PHYS/QHP W/O PROGRAMMING | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
63664 | Revise spine eltrd plate | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
L8686 | Implt nrostm pls gen sng non | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
L8680 | KIT NRSTM 40CM STIMLOC . | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
95971 | PR ELEC ALYS IMPLT NPGT SMPL SP/PN NPGT PRGRMG | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
L8687 | KIT NEUROSTIMULATOR SENZA IPG STERILE LATEX FREE DISPOSABLE | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
1999 | ANESTHESIOLOGY GROUP | CPT | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
95973 | Analyze neurostim complex | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
L8685 | Implt nrostm pls gen sng rec | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
63685 | PR INSJ/RPLCMT SPINAL NPG/RCVR POCKET CRTJ&CONNJ | HCPCS | |CPT||63650||Percutaneous implantation of neurostimulator electrode array; epidural|
|63655||Laminectomy for implantation of neurostimulator electrode plate/paddle; epidural|
|63661||Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63662||Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy (new code 1/1/10)|
|63663||Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed (new code 1/1/10)|
|63664||Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed (new code 1/1/10)|
|63685||Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling|
|63688||Revision or removal of implanted spinal neurostimulator pulse generator or receiver|
|95970, 95971, 95972, 95973||Neurostimulator programming and analysis code range|
|ICD-9 Procedure||03.93||Insertion or replacement of spinal neurostimulator|
|03.94||Removal of spinal neurostimulator lead(s)|
|86.05||Incision with removal of foreign body or device from skin and subcutaneous tissue (used to report removal of a neurostimulator pulse generator)|
|86.94||Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable|
|86.95||Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable|
|86.97||Insertion or replacement of single array rechargeable neurostimulator pulse generator (new code effective 10/1/05)|
|86.98||Insertion or replacement of dual array rechargeable neurostimulator pulse generation (new code effective 10/1/05)|
|ICD-9 Diagnosis||See “Pain” in ICD-9 diagnosis index|
|HCPCS||L8680||Implantable neurostimulator electrode, each (new code effective 1/1/06)|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension (new code effective 1/1/06)|
|L8686||Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension (new code effective 1/1/06)|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension (new code effective 1/1/06)|
|L8688||Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension (new code effective 1/1/06)|
|ICD-10-CM (effective 10/1/14)||This list is a representative list of severe and chronic pain of the trunk and limbs diagnosis codes.|
|G56.40 -G56.42||Causalgia of upper limb code range|
|G57.70 -G57.72||Causalgia of lower limb code range|
|G89.21 -G89.8||Chronic pain, not elsewhere classified, code range|
|G89.4||Chronic pain syndrome|
|G90.50 -G90.59||Complex regional pain syndrome I (CRPS I), code range|
|M25.50 -M25.579||Pain in joint, code range|
|M54.10 -M54.18||Radiculopathy, code range|
|M54.30 -M54.32||Sciatica, code range|
|M54.40 -M54.42||Lumbago with sciatica, code range|
|M54.5||Low back pain|
|M54.6||Pain in thoracic spine|
|M54.81, M54.89||Other dorsalgia codes|
|M79.60 -M79.676||Pain in limb, hand, foot, fingers and toes code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|Surgical, central nervous system, insertion, spinal canal, neurostimulator lead, code by approach|
|00HV0MZ, 00HV3MZ, 00HV4MZ||Surgical, central nervous system, insertion, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, removal, spinal canal, neurostimulator lead, code by approach|
|00PV0MZ, 00PV3MZ, 00PV4MZ||Surgical, central nervous system, removal, spinal cord, neurostimulator lead, code by approach|
|00WU0MZ, 00WU3MZ, 00WU4MZ||Surgical, central nervous system, revision, spinal canal, neurostimulator lead, code by approach|
|00WV0MZ, 00WV3MZ, 00WV4MZ||Surgical, central nervous system, revision, spinal cord, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7, 0JH63M8, 0JH63M9, 0JH70M6, 0JH70M7, 0JH70M8, 0JH70M9, 0JH73M6, 0JH73M7, 0JH73M8, 0JH73M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9||Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part, approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach (there aren’t ICD-10-PCS codes for removal of stimulator generator from other body parts)|
|Type of Service||Surgical|
|Place of Service||Inpatient/Outpatient|
Electrical Nerve Stimulation, Spinal
Spinal Cord Stimulation
Stimulation, Electrical, Spinal Cord
|03/31/96||Add to Surgery section||New policy|
|04/01/98||Replace policy||Policy cross-referenced to No. 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. |
1999 | ANESTHESIOLOGY GROUP | CPT | 7.01.63|
|07/10/98||Replace policy||Policy updated and revised|
|11/15/98||Coding update||1999 CPT coding release|
|04/29/03||Replace policy||Policy updated; new policy statement added, stating that spinal cord stimulation is investigational as a treatment of critical limb ischemia|
|11/9/04||Replace policy||Policy updated; no change to policy statement. Coding updated|
|08/17/05||Replace policy||Policy updated with literature search and coding updated; no change to policy statement|
|12/14/05||Replace policy – coding update only||Coding updated|
|12/12/06||Replace policy||Policy updated with literature search; no change to policy statement; reference numbers 7 – 9 added|
|03/13/08||Replace policy||Policy updated with literature search; references 10 – 13 added; no change to policy statements|
|01/08/09||Replace policy||Policy updated with literature search; references 14–25 added. Use in refractory angina added as investigational indication.|
|01/14/10||Replace policy||Policy updated with literature search; reference numbers 26-29 added; no change to policy statements|
|01/13/11||Replace policy||Policy updated with literature search. Rationale extensively reqritten; references numbers 15 and 16 added, other references reordered or removed. No change to policy statements.|
|1/12/12||Replace policy||Policy updated with literature search. Reference numbers 16, 17 and 18 added, other references reordered or removed. No change to policy statements|
|1/10/13||Replace policy||Policy updated with literature search. |
780 | Telemedicine General Classification | RC | The randomization treatment was reported in enough detail to make sure that it was suitable in four research, but had not been reported in three. Furthermore, all scholarly research attained an acceptable randomization concealment and blinded the procedure groupings effectively. Finally, five from the seven content reported the real amount and the reason why for just about any dropouts or treatment withdrawals. Desk?2 Evaluation of the grade of the KLRC1 antibody research contained in the meta-analysis SVR12 in the SL and SLR Groupings The meta-analysis of SVR12 in every sufferers receiving SLR and SL therapy is proven in Fig.?2. The SVR12 in genotype 1 HCV infections sufferers ranged from 70 to 100?%. The pooled data demonstrated that there is no statistically factor in the entire proportion of sufferers achieving SVR12 between your two groupings (RR?=?1.002, 95?% CI?=?0.988, 1.017, P?=?0.780, I 2?=?5.3?%). Fig. |
780 | Telemedicine General Classification | RC | Furthermore, all scholarly research attained an acceptable randomization concealment and blinded the procedure groupings effectively. Finally, five from the seven content reported the real amount and the reason why for just about any dropouts or treatment withdrawals. Desk?2 Evaluation of the grade of the KLRC1 antibody research contained in the meta-analysis SVR12 in the SL and SLR Groupings The meta-analysis of SVR12 in every sufferers receiving SLR and SL therapy is proven in Fig.?2. The SVR12 in genotype 1 HCV infections sufferers ranged from 70 to 100?%. The pooled data demonstrated that there is no statistically factor in the entire proportion of sufferers achieving SVR12 between your two groupings (RR?=?1.002, 95?% CI?=?0.988, 1.017, P?=?0.780, I 2?=?5.3?%). Fig. ?2 Meta-analysis looking at the SVR12 price between your SLR and SL groupings Predicated on treatment history, the existence or lack of duration and 86639-52-3 manufacture cirrhosis of treatment, we performed subgroup analyses subsequently. |
780 | Telemedicine General Classification | RC | Finally, five from the seven content reported the real amount and the reason why for just about any dropouts or treatment withdrawals. Desk?2 Evaluation of the grade of the KLRC1 antibody research contained in the meta-analysis SVR12 in the SL and SLR Groupings The meta-analysis of SVR12 in every sufferers receiving SLR and SL therapy is proven in Fig.?2. The SVR12 in genotype 1 HCV infections sufferers ranged from 70 to 100?%. The pooled data demonstrated that there is no statistically factor in the entire proportion of sufferers achieving SVR12 between your two groupings (RR?=?1.002, 95?% CI?=?0.988, 1.017, P?=?0.780, I 2?=?5.3?%). Fig. ?2 Meta-analysis looking at the SVR12 price between your SLR and SL groupings Predicated on treatment history, the existence or lack of duration and 86639-52-3 manufacture cirrhosis of treatment, we performed subgroup analyses subsequently. Treatment-na?ve sufferers that received the SLR and SL regimens had an identical possibility of achieving SVR12 (RR?=?0.994, 95?% CI?=?0.975, 1.014, P?=?0.567, I 2?=?0.0?%). |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Neurological Myofascial pain syndrome – Orthopaedic. Myofascial Pain . Myofascial pain refers to soft tissue pain usually arising from trauma, repetitive activities, or poor posture. Myofascial Pain Syndromes – Orthopaedic Web Links
“May our spirit fill us with understanding of victory and defeat, the gift of collaboration, the wisdom to choose the right path, and opportunities to inspire hope.” Get the latest updates on ICD-10 Codes, ICD 9 Codes 2010, ICD-9-CM Codes, HCPCS Codes, Medical Coding, Modifier 59 E124 / The Journal of Manual Manipulative Therapy, 2006 The Journal of Manual Manipulative Therapy Vol. 14 No. 4 (2006), E124 – E171 Myofascial Trigger Points and
Myofascial pain syndrome – LuMriX XML Solutions for Enterprises
Free official medical coding data for 2008 ICD-9-CM diagnosis code 338.2 (2012 also), including ICD-9-CM coding notes, detailed description and associated index data. 338.4 Chronic pain syndrome, Chronic pain associated with significant psychosocial dysfunction – ICD-9-CM Vol. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Myofascial Pain . Myofascial pain refers to soft tissue pain usually arising from trauma, repetitive activities, or poor posture. Myofascial Pain Syndromes – Orthopaedic Web Links
“May our spirit fill us with understanding of victory and defeat, the gift of collaboration, the wisdom to choose the right path, and opportunities to inspire hope.” Get the latest updates on ICD-10 Codes, ICD 9 Codes 2010, ICD-9-CM Codes, HCPCS Codes, Medical Coding, Modifier 59 E124 / The Journal of Manual Manipulative Therapy, 2006 The Journal of Manual Manipulative Therapy Vol. 14 No. 4 (2006), E124 – E171 Myofascial Trigger Points and
Myofascial pain syndrome – LuMriX XML Solutions for Enterprises
Free official medical coding data for 2008 ICD-9-CM diagnosis code 338.2 (2012 also), including ICD-9-CM coding notes, detailed description and associated index data. 338.4 Chronic pain syndrome, Chronic pain associated with significant psychosocial dysfunction – ICD-9-CM Vol. 1 Diagnostic Codes – FindACode.com Gout is a medical condition that usually presents with recurrent s of acute inflammatory arthritis (red, tender, hot, swollen joint). |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Myofascial pain refers to soft tissue pain usually arising from trauma, repetitive activities, or poor posture. Myofascial Pain Syndromes – Orthopaedic Web Links
“May our spirit fill us with understanding of victory and defeat, the gift of collaboration, the wisdom to choose the right path, and opportunities to inspire hope.” Get the latest updates on ICD-10 Codes, ICD 9 Codes 2010, ICD-9-CM Codes, HCPCS Codes, Medical Coding, Modifier 59 E124 / The Journal of Manual Manipulative Therapy, 2006 The Journal of Manual Manipulative Therapy Vol. 14 No. 4 (2006), E124 – E171 Myofascial Trigger Points and
Myofascial pain syndrome – LuMriX XML Solutions for Enterprises
Free official medical coding data for 2008 ICD-9-CM diagnosis code 338.2 (2012 also), including ICD-9-CM coding notes, detailed description and associated index data. 338.4 Chronic pain syndrome, Chronic pain associated with significant psychosocial dysfunction – ICD-9-CM Vol. 1 Diagnostic Codes – FindACode.com Gout is a medical condition that usually presents with recurrent s of acute inflammatory arthritis (red, tender, hot, swollen joint). ^ Gout is a disease
Fibromyalgia/Myofascial Pain Syndromes – Portsmouth,Va
Everything you need to know about mechanical low back pain syndrome icd 9, including the most common causes, symptoms and treatments. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Myofascial Pain Syndromes – Orthopaedic Web Links
“May our spirit fill us with understanding of victory and defeat, the gift of collaboration, the wisdom to choose the right path, and opportunities to inspire hope.” Get the latest updates on ICD-10 Codes, ICD 9 Codes 2010, ICD-9-CM Codes, HCPCS Codes, Medical Coding, Modifier 59 E124 / The Journal of Manual Manipulative Therapy, 2006 The Journal of Manual Manipulative Therapy Vol. 14 No. 4 (2006), E124 – E171 Myofascial Trigger Points and
Myofascial pain syndrome – LuMriX XML Solutions for Enterprises
Free official medical coding data for 2008 ICD-9-CM diagnosis code 338.2 (2012 also), including ICD-9-CM coding notes, detailed description and associated index data. 338.4 Chronic pain syndrome, Chronic pain associated with significant psychosocial dysfunction – ICD-9-CM Vol. 1 Diagnostic Codes – FindACode.com Gout is a medical condition that usually presents with recurrent s of acute inflammatory arthritis (red, tender, hot, swollen joint). ^ Gout is a disease
Fibromyalgia/Myofascial Pain Syndromes – Portsmouth,Va
Everything you need to know about mechanical low back pain syndrome icd 9, including the most common causes, symptoms and treatments. Myofascial Pain Syndrome . |
367 | Operating Room Services Kidney Transplant | RC | "Expression of human herpesvirus 8 in primary pulmonary hypertension". N. Engl. J. Med. 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). |
952 | Other Therapeutic Services Kinesiotherapy | RC | "Expression of human herpesvirus 8 in primary pulmonary hypertension". N. Engl. J. Med. 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). |
0351 | HB RADIANT-GRANT-PKD CT ANGIO LOW EXT W/WO | RC | "Expression of human herpesvirus 8 in primary pulmonary hypertension". N. Engl. J. Med. 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). |
367 | Operating Room Services Kidney Transplant | RC | N. Engl. J. Med. 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". |
952 | Other Therapeutic Services Kinesiotherapy | RC | N. Engl. J. Med. 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". |
0351 | HB RADIANT-GRANT-PKD CT ANGIO LOW EXT W/WO | RC | N. Engl. J. Med. 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". |
367 | Operating Room Services Kidney Transplant | RC | J. Med. 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". Thorax 56 (11): 888–890. |
952 | Other Therapeutic Services Kinesiotherapy | RC | J. Med. 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". Thorax 56 (11): 888–890. |
0351 | HB RADIANT-GRANT-PKD CT ANGIO LOW EXT W/WO | RC | J. Med. 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". Thorax 56 (11): 888–890. |
367 | Operating Room Services Kidney Transplant | RC | 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". Thorax 56 (11): 888–890. doi:10.1136/thorax.56.11.888. |
952 | Other Therapeutic Services Kinesiotherapy | RC | 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". Thorax 56 (11): 888–890. doi:10.1136/thorax.56.11.888. |
0351 | HB RADIANT-GRANT-PKD CT ANGIO LOW EXT W/WO | RC | 349 (12): 1113–22. doi:10.1056/NEJMoa035115. PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". Thorax 56 (11): 888–890. doi:10.1136/thorax.56.11.888. |
367 | Operating Room Services Kidney Transplant | RC | PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". Thorax 56 (11): 888–890. doi:10.1136/thorax.56.11.888. PMC 1745964. PMID 11641516. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1745964. |
952 | Other Therapeutic Services Kinesiotherapy | RC | PMID 13679525. http://content.nejm.org/cgi/content/full/349/12/1113. - ^ Rudarakanchana, N; Trembath RC, Morrell NW (November 2001). "New insights into the pathogenesis and treatment of primary pulmonary hypertension". Thorax 56 (11): 888–890. doi:10.1136/thorax.56.11.888. PMC 1745964. PMID 11641516. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1745964. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Medical Coding BooksThe term "medical coding books" generally describes the three coding books that medical coders use; the CPT, ICD-9-CM, and HCPCS. These coding books are used to translate a written medical record into number sets prior to insurance submission. Number sets, also called medical codes, each represent a unique descriptor found in one of the three books. CPT, ICD-9-CM, & HCPCSThree Medical Coding Books:
Codes can be selected from one, two, or all three medical coding books when coding a single medical record. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Medical Coding BooksThe term "medical coding books" generally describes the three coding books that medical coders use; the CPT, ICD-9-CM, and HCPCS. These coding books are used to translate a written medical record into number sets prior to insurance submission. Number sets, also called medical codes, each represent a unique descriptor found in one of the three books. CPT, ICD-9-CM, & HCPCSThree Medical Coding Books:
Codes can be selected from one, two, or all three medical coding books when coding a single medical record. Each book is distinct from the other, carrying it's own set of unique codes, descriptors, and guidelines. The CPT book was founded by the American Medical Association (AMA) in 1966 and is updated annually with changes effective January 1st of each year. Current Procedural Terminology (CPT)
The Current Procedural Terminology book contains medical codes that are often called CPT codes or National Level I codes. |
K0011 | Stnd wt pwr whlchr w control | HCPCS | HCPCS codes are five digits in length with no decimal holders and are alphanumeric in nature. Each codes begins with a letter and is followed by four numbers. The HCPCS book structured very similar to the CPT book. HCPCS Code ExamplesK0011 - Standard-weight frame motorized power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking
A5120 - Skin barrier, wipes or swabs, each
Q4011 - Cast supplies, short arm cast, pediatric (0-10 years), plaster. ~ The Table of Drugs with drugs listed alphabeticaly is next. ~ HCPCS modifiers listed with their full description is located between the Table of Drugs and the Tabula index. ~ The Tabular index lists all codes with their full description, conventions, and notations and is located in the center of the book. |
Q4011 | Cast sup sht arm ped plaster | HCPCS | HCPCS codes are five digits in length with no decimal holders and are alphanumeric in nature. Each codes begins with a letter and is followed by four numbers. The HCPCS book structured very similar to the CPT book. HCPCS Code ExamplesK0011 - Standard-weight frame motorized power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking
A5120 - Skin barrier, wipes or swabs, each
Q4011 - Cast supplies, short arm cast, pediatric (0-10 years), plaster. ~ The Table of Drugs with drugs listed alphabeticaly is next. ~ HCPCS modifiers listed with their full description is located between the Table of Drugs and the Tabula index. ~ The Tabular index lists all codes with their full description, conventions, and notations and is located in the center of the book. |
A5120 | Skin barrier, wipes or swabs, each | HCPCS | HCPCS codes are five digits in length with no decimal holders and are alphanumeric in nature. Each codes begins with a letter and is followed by four numbers. The HCPCS book structured very similar to the CPT book. HCPCS Code ExamplesK0011 - Standard-weight frame motorized power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking
A5120 - Skin barrier, wipes or swabs, each
Q4011 - Cast supplies, short arm cast, pediatric (0-10 years), plaster. ~ The Table of Drugs with drugs listed alphabeticaly is next. ~ HCPCS modifiers listed with their full description is located between the Table of Drugs and the Tabula index. ~ The Tabular index lists all codes with their full description, conventions, and notations and is located in the center of the book. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | HCPCS codes are five digits in length with no decimal holders and are alphanumeric in nature. Each codes begins with a letter and is followed by four numbers. The HCPCS book structured very similar to the CPT book. HCPCS Code ExamplesK0011 - Standard-weight frame motorized power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking
A5120 - Skin barrier, wipes or swabs, each
Q4011 - Cast supplies, short arm cast, pediatric (0-10 years), plaster. ~ The Table of Drugs with drugs listed alphabeticaly is next. ~ HCPCS modifiers listed with their full description is located between the Table of Drugs and the Tabula index. ~ The Tabular index lists all codes with their full description, conventions, and notations and is located in the center of the book. |
0110 | ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION | RC | American Journal of Psychiatry Residents’ Journal, 11(7), 1510–1517. https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. |
0101 | Med-Surg | RC | American Journal of Psychiatry Residents’ Journal, 11(7), 1510–1517. https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. |
450 | XXX TESTING VISIT | RC | American Journal of Psychiatry Residents’ Journal, 11(7), 1510–1517. https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. |
0801 | Inpatient Renal Dialysis - Inpatient Hemodialysis | RC | American Journal of Psychiatry Residents’ Journal, 11(7), 1510–1517. https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. |
0120 | ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION | RC | American Journal of Psychiatry Residents’ Journal, 11(7), 1510–1517. https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. |
110 | PRIVATE ROOM | RC | American Journal of Psychiatry Residents’ Journal, 11(7), 1510–1517. https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. |
0179 | Nursery - Other Nursery | RC | American Journal of Psychiatry Residents’ Journal, 11(7), 1510–1517. https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. |
0110 | ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION | RC | https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. - World Health Organization. |
0101 | Med-Surg | RC | https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. - World Health Organization. |
450 | XXX TESTING VISIT | RC | https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. - World Health Organization. |
0801 | Inpatient Renal Dialysis - Inpatient Hemodialysis | RC | https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. - World Health Organization. |
0120 | ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION | RC | https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. - World Health Organization. |
110 | PRIVATE ROOM | RC | https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. - World Health Organization. |
0179 | Nursery - Other Nursery | RC | https://doi.org/10.1176/appi.ajp-rj.2016.110701
- Tasca, C. (2012). Women And Hysteria In The History Of Mental Health. Clinical Practice & Epidemiology in Mental Health, 8(1), 110–119. https://doi.org/10.2174/1745017901208010110
- Williams, C., Carson, A., Smith, S., Sharpe, M., Cavanagh, J., & Kent, C. (2017). Overcoming functional neurological symptoms: a five areas approach. CRC Press. - World Health Organization. |
81599 | Unlisted multianalyte assay with algorithmic analysis | CPT | (18)
FMR1 (Fragile X mental retardation 1) (e.g., fragile X mental retardation) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles
FMR1 (Fragile X mental retardation 1) (e.g., fragile X mental retardation) gene analysis; characterization of alleles (e.g., expanded size and methylation status)
FMR1: Fragile X mental retardation 1
FMRP: Fragile X mental retardation protein
FXS: Fragile X syndrome
FXTAS: Fragile X-associated tremor/ ataxia syndrome
PCR: Polymerase chain reaction
POI: Premature ovarian insufficiency
New Policy. Add to Genetic Testing section. Genetic testing for FMR1 mutations may be considered medically necessary for specific patient populations. Update Coding Section – ICD-10 codes are now effective 10/01/2014. Coding update. CPT codes 83890 – 83913 deleted as of 12/31/12; CPT codes 81200 – 81479 and 81599, effective 1/1/13, are added to the policy. Update Related Policies. |
81599 | Unlisted multianalyte assay with algorithmic analysis | CPT | Genetic testing for FMR1 mutations may be considered medically necessary for specific patient populations. Update Coding Section – ICD-10 codes are now effective 10/01/2014. Coding update. CPT codes 83890 – 83913 deleted as of 12/31/12; CPT codes 81200 – 81479 and 81599, effective 1/1/13, are added to the policy. Update Related Policies. Add 12.04.91. Replace policy. |
81599 | Unlisted multianalyte assay with algorithmic analysis | CPT | Coding update. CPT codes 83890 – 83913 deleted as of 12/31/12; CPT codes 81200 – 81479 and 81599, effective 1/1/13, are added to the policy. Update Related Policies. Add 12.04.91. Replace policy. Policy updated with literature search through April 2013. No new references added. |
81599 | Unlisted multianalyte assay with algorithmic analysis | CPT | Add 12.04.305. Update Related Policies; add 12.04.109, effective 12/9/13. Annual Review. Policy updated with literature review through May 31, 2014; references 3-4, 6-8, 10-15, and 17-18 added; reference 2 deleted; reference 1 updated. Policy statements and entire policy updated to reflect current DSM-V diagnostic categories, i.e., “intellectual disability” replaces “mental retardation.” Policy statement on testing relatives of affected individuals reworded for clarity. Otherwise, no change to policy statements. CPT code range 81200-81479 and 81599 removed; there are specific CPT codes as listed in the policy. |
81599 | Unlisted multianalyte assay with algorithmic analysis | CPT | Policy updated with literature review through May 31, 2014; references 3-4, 6-8, 10-15, and 17-18 added; reference 2 deleted; reference 1 updated. Policy statements and entire policy updated to reflect current DSM-V diagnostic categories, i.e., “intellectual disability” replaces “mental retardation.” Policy statement on testing relatives of affected individuals reworded for clarity. Otherwise, no change to policy statements. CPT code range 81200-81479 and 81599 removed; there are specific CPT codes as listed in the policy. ICD-9 and ICD-10 diagnosis codes removed; they do not impact utilization of the policy. Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. |
81599 | Unlisted multianalyte assay with algorithmic analysis | CPT | Policy statements and entire policy updated to reflect current DSM-V diagnostic categories, i.e., “intellectual disability” replaces “mental retardation.” Policy statement on testing relatives of affected individuals reworded for clarity. Otherwise, no change to policy statements. CPT code range 81200-81479 and 81599 removed; there are specific CPT codes as listed in the policy. ICD-9 and ICD-10 diagnosis codes removed; they do not impact utilization of the policy. Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | The ABN may differ based on the source which provides it to you. The ABN enables you to choose whether or not to receive the care in question and bear financial responsibility for the service on your own If Medicare denies reimbursement. The note must state why the provider believes Medicare will refuse payment. Billing Executive – a Medical Billing and Coding Knowledge Base for Physicians, Office staff, Medical Billers and Coders, including resources pertaining to HCPCS Codes, CPT Codes, ICD-10 billing codes, Modifiers, POS Codes, Revenue Codes, Billing Errors, Denials and Rejections. We have more than 10 years experience in US Medical Billing and hand-on experience in Web Management, SEO, Content Marketing & Business Development with Research as a special forte. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | The ABN enables you to choose whether or not to receive the care in question and bear financial responsibility for the service on your own If Medicare denies reimbursement. The note must state why the provider believes Medicare will refuse payment. Billing Executive – a Medical Billing and Coding Knowledge Base for Physicians, Office staff, Medical Billers and Coders, including resources pertaining to HCPCS Codes, CPT Codes, ICD-10 billing codes, Modifiers, POS Codes, Revenue Codes, Billing Errors, Denials and Rejections. We have more than 10 years experience in US Medical Billing and hand-on experience in Web Management, SEO, Content Marketing & Business Development with Research as a special forte. |
404 | Other Imaging Services Positron Emission Tomography | RC | Mutations account for less than 10% of patients with HPC. Chronic susceptibility to pancreatitis
||Mutations in the CTRC gene encoding the digestive enzyme chymotrypsin C have been shown to increase the risk of chronic pancreatitis. The CTRC gene encodes a protease that functions to prevent premature trypsinogen activation in the pancreas as well as promote trypsin, M. Loss-of-function mutations in CTRC predispose to pancreatitis. Mutations account for less than 5% of patients with ICP. Purpose: Confirmation of Clinical Diagnosis
Methodology: Next-Generation Sequencing
Test Requisition: Sequencing Requisition
Specimen Requirements: 2-5 mL Blood-Lavender Top Tube
Panel CPT Codes: 81404x2, 81223, 81479 Cost: $3500.00 Oklahoma Medicaid requires preauthorization for this test)
Provider can also select specific genes to be analyzed, this will affect pricing and CPT codes used for insurance filing. Turn-around-time: 5-6 weeks
1. Greer JB, Whitcomb DC. |
404 | Other Imaging Services Positron Emission Tomography | RC | Chronic susceptibility to pancreatitis
||Mutations in the CTRC gene encoding the digestive enzyme chymotrypsin C have been shown to increase the risk of chronic pancreatitis. The CTRC gene encodes a protease that functions to prevent premature trypsinogen activation in the pancreas as well as promote trypsin, M. Loss-of-function mutations in CTRC predispose to pancreatitis. Mutations account for less than 5% of patients with ICP. Purpose: Confirmation of Clinical Diagnosis
Methodology: Next-Generation Sequencing
Test Requisition: Sequencing Requisition
Specimen Requirements: 2-5 mL Blood-Lavender Top Tube
Panel CPT Codes: 81404x2, 81223, 81479 Cost: $3500.00 Oklahoma Medicaid requires preauthorization for this test)
Provider can also select specific genes to be analyzed, this will affect pricing and CPT codes used for insurance filing. Turn-around-time: 5-6 weeks
1. Greer JB, Whitcomb DC. Inflammation and pancreatic cancer: an evidence-based review. |
404 | Other Imaging Services Positron Emission Tomography | RC | The CTRC gene encodes a protease that functions to prevent premature trypsinogen activation in the pancreas as well as promote trypsin, M. Loss-of-function mutations in CTRC predispose to pancreatitis. Mutations account for less than 5% of patients with ICP. Purpose: Confirmation of Clinical Diagnosis
Methodology: Next-Generation Sequencing
Test Requisition: Sequencing Requisition
Specimen Requirements: 2-5 mL Blood-Lavender Top Tube
Panel CPT Codes: 81404x2, 81223, 81479 Cost: $3500.00 Oklahoma Medicaid requires preauthorization for this test)
Provider can also select specific genes to be analyzed, this will affect pricing and CPT codes used for insurance filing. Turn-around-time: 5-6 weeks
1. Greer JB, Whitcomb DC. Inflammation and pancreatic cancer: an evidence-based review. Curr Opin Pharmacol. |
15878 | Suction lipectomy upr extrem | HCPCS | POLICY GUIDELINESA multispecialty working group defines primary focal hyperhidrosis as a condition that is characterized by visible, excessive sweating of at least 6 months’ duration without apparent cause and with at least 2 of the following features: bilateral and relatively symmetric sweating, impairment of daily activities, frequency of at least once per week, age at onset younger than 25 years, positive family history, and cessation of focal sweating during sleep. In the hyperhidrosis disease severity scale, patients rate the severity of symptoms on a scale of 1-4:
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
9/9/2004: Policy statement "Treatment of hyperhidrosis with botulinum toxin is considered investigational and not medically necessary since it is not FDA approved for this indication." changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. |
17999 | UNLISTED PROC SKIN SUBQ | HCPCS | POLICY GUIDELINESA multispecialty working group defines primary focal hyperhidrosis as a condition that is characterized by visible, excessive sweating of at least 6 months’ duration without apparent cause and with at least 2 of the following features: bilateral and relatively symmetric sweating, impairment of daily activities, frequency of at least once per week, age at onset younger than 25 years, positive family history, and cessation of focal sweating during sleep. In the hyperhidrosis disease severity scale, patients rate the severity of symptoms on a scale of 1-4:
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
9/9/2004: Policy statement "Treatment of hyperhidrosis with botulinum toxin is considered investigational and not medically necessary since it is not FDA approved for this indication." changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. |
97033 | SBT PTA IONTOPHORESIS EACH 15 MIN | HCPCS | POLICY GUIDELINESA multispecialty working group defines primary focal hyperhidrosis as a condition that is characterized by visible, excessive sweating of at least 6 months’ duration without apparent cause and with at least 2 of the following features: bilateral and relatively symmetric sweating, impairment of daily activities, frequency of at least once per week, age at onset younger than 25 years, positive family history, and cessation of focal sweating during sleep. In the hyperhidrosis disease severity scale, patients rate the severity of symptoms on a scale of 1-4:
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
9/9/2004: Policy statement "Treatment of hyperhidrosis with botulinum toxin is considered investigational and not medically necessary since it is not FDA approved for this indication." changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | POLICY GUIDELINESA multispecialty working group defines primary focal hyperhidrosis as a condition that is characterized by visible, excessive sweating of at least 6 months’ duration without apparent cause and with at least 2 of the following features: bilateral and relatively symmetric sweating, impairment of daily activities, frequency of at least once per week, age at onset younger than 25 years, positive family history, and cessation of focal sweating during sleep. In the hyperhidrosis disease severity scale, patients rate the severity of symptoms on a scale of 1-4:
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
9/9/2004: Policy statement "Treatment of hyperhidrosis with botulinum toxin is considered investigational and not medically necessary since it is not FDA approved for this indication." changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. |
J0585 | PR INJECTION,ONABOTULINUMTOXINA 1 UNITS | HCPCS | POLICY GUIDELINESA multispecialty working group defines primary focal hyperhidrosis as a condition that is characterized by visible, excessive sweating of at least 6 months’ duration without apparent cause and with at least 2 of the following features: bilateral and relatively symmetric sweating, impairment of daily activities, frequency of at least once per week, age at onset younger than 25 years, positive family history, and cessation of focal sweating during sleep. In the hyperhidrosis disease severity scale, patients rate the severity of symptoms on a scale of 1-4:
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
9/9/2004: Policy statement "Treatment of hyperhidrosis with botulinum toxin is considered investigational and not medically necessary since it is not FDA approved for this indication." changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. |
15878 | Suction lipectomy upr extrem | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
9/9/2004: Policy statement "Treatment of hyperhidrosis with botulinum toxin is considered investigational and not medically necessary since it is not FDA approved for this indication." changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." ICD-9 diagnosis code 780.8 description "Hyperhidrosis (includes palmar hyperhidrosis, axillary hyperhidrosis, and primary hyperhidrosis)" revised to read "Generalized Hyperhidrosis" with a Note change from "See POLICY statement regarding the coverage of palmar, axillary, and primary hyperhidrosis added 9/9/2004" to "See POLICY statement regarding the coverage of the various types of hyperhidrosis"
3/14/2006: Coding updated. |
17999 | UNLISTED PROC SKIN SUBQ | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
9/9/2004: Policy statement "Treatment of hyperhidrosis with botulinum toxin is considered investigational and not medically necessary since it is not FDA approved for this indication." changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." ICD-9 diagnosis code 780.8 description "Hyperhidrosis (includes palmar hyperhidrosis, axillary hyperhidrosis, and primary hyperhidrosis)" revised to read "Generalized Hyperhidrosis" with a Note change from "See POLICY statement regarding the coverage of palmar, axillary, and primary hyperhidrosis added 9/9/2004" to "See POLICY statement regarding the coverage of the various types of hyperhidrosis"
3/14/2006: Coding updated. |
97033 | SBT PTA IONTOPHORESIS EACH 15 MIN | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
9/9/2004: Policy statement "Treatment of hyperhidrosis with botulinum toxin is considered investigational and not medically necessary since it is not FDA approved for this indication." changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." ICD-9 diagnosis code 780.8 description "Hyperhidrosis (includes palmar hyperhidrosis, axillary hyperhidrosis, and primary hyperhidrosis)" revised to read "Generalized Hyperhidrosis" with a Note change from "See POLICY statement regarding the coverage of palmar, axillary, and primary hyperhidrosis added 9/9/2004" to "See POLICY statement regarding the coverage of the various types of hyperhidrosis"
3/14/2006: Coding updated. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
9/9/2004: Policy statement "Treatment of hyperhidrosis with botulinum toxin is considered investigational and not medically necessary since it is not FDA approved for this indication." changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." ICD-9 diagnosis code 780.8 description "Hyperhidrosis (includes palmar hyperhidrosis, axillary hyperhidrosis, and primary hyperhidrosis)" revised to read "Generalized Hyperhidrosis" with a Note change from "See POLICY statement regarding the coverage of palmar, axillary, and primary hyperhidrosis added 9/9/2004" to "See POLICY statement regarding the coverage of the various types of hyperhidrosis"
3/14/2006: Coding updated. |
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