(Medicare Claims Processing Manual)

330  Percutaneous Image -guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)  (Rev.  2959, Issued: 05- 16-14, Effective: 01 -09-14, Implementation: 10- 06-14)  PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area.  This is a procedure proposed as a treatment for symptomatic LSS unresponsive to conservative therapy.  Thi s procedure is generally described as a non -invasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum.  The procedure is performed under x -ray guidance (e.g., fluoroscopic, CT)  with the assistance of contrast media to identify and monitor the compressed area via epiduragram. For complete Medical coverage guidelines, see National Coverage Determinations (NCD) Manual (Pub 100- 03) 150.13.   330.1  Claims Processing Requirements for Percutaneous Image -guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) on Professional Claims  (Rev. 3811, Issued: 07- 25-17, Effective: 12 -07-16, Implementation: 06- 27-17)   For claims with dates of service on or after January 9, 2014, PILD (procedure code 0275T) is a covered service when billed as part of a clinical trial approved by CMS.  The description for CPT 0275T is Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy, any method, under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar.   For claims with dates of service on or after January 1, 2015, PILD (procedure code G0276) is a covered service when billed as part of a clinical trial approved by CMS.  HCPCS G0276 is Blinded procedure for lumbar stenosis, percutaneous image- guided lumbar  decompression (PILD), or placebo control, performed in an approved coverage with evidence development (CED) clinical trial.   Effective for dates of service on or after December 7, 2016, Medicare will cover PILD under CED for beneficiaries with LSS who are enrolled in a CMS -approved prospective longitudinal study for PILD procedures using a FDA -approved/cleared device that comple ted a CMS -approved randomized, controlled clinical trial (RCT) that met the criteria listed in the January 2014 NCD (see CR 8757, transmittal # 2959, dated May 16, 2014).    The claim may only contain one of these procedure codes, not both.  To use G0276, the procedure must be performed in an approved CED clinical trial that is randomized, blinded, and contains a placebo control arm of the trial.  CMS will cover procedure code 0275T for PILD only when the procedure is performed within any other CED approved clinical trial.  Regardless of the type of CED approved clinical trial (e.g. G0276 vs 0275T), PILD is only covered when billed for the ICD -9 diagnosis of 724.01- 724.03 or the ICD -10 diagnosis of M48.05- M48.07, when billed in places of service 22 (Outpatient) or 24 (Ambulatory Surgical Center), when billed along with V70.7 (ICD -9) or Z00.6 (ICD -10) in either the primary/secondary positions, and when billed with modifier Q0.   Additionally, per Transmittal 2805 (Change Request 8401), issued October 30, 2013, all claims for clinical trials must contain the 8 digit clinical trial identifier number.   The following message(s) shall be used to notify providers of return situations that may occur:   Professional Claims 8-digit Clinical Trial Number   For PILD claims with procedure code 0275T with dates of service on or after January 9, 2014 , or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD only when billed with the numeric, 8-digit clinical trial identifier number preceded by the two alpha characters CT when placed in  Field 19 of paper Form CMS -1500, or when entered without the CT prefix in the electronic 837P in Loop 2300 REF02 (REF01=P4).  Claims for PILD which are billed wit hout an 8-digit clinical trial identifier number shall be returned as unprocessable.   The following messages shall be used when Medicare contractors return PILD claims billed without an 8 -digit clinical trial identifier number as unprocessable:   Claims Adjustment Reason Code 16:  Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.   Remittance Advice Remark Code N721: This service is only covered when performed as part of a clinical trial.   Remittance Advice Remark Code MA50: Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number .  Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   Professional Claims Place of Service  22 or 24   For PILD claims with procedure code 0275T with dates of service on or after January 9, 2014 , or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD for LSS claims only when billed in place of service 22 or 24.  Claims for PILD which are billed in any other place of service shall be returned a s unprocessable.   The following messages shall be used when Medicare contractors return PILD claims not billed in place of service 22 or 24:   Claims Adjustment Reason Code 58:  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.   Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   Professional Claims Modifier  Q0   For PILD claims with procedure code 0275T with dates of service on or after January 9, 2014 , or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD for LSS claims only when billed with modifier Q0.  Claims for PILD which are billed without modifier Q0 shall be returned as unproce ssable.   The following messages shall be used when Medicare contractors return PILD claims billed without modifier Q0 as unprocessable:   Claims Adjustment Reason Code 4:  The procedure code is inconsistent with the modifier used or a required modifier is missing.   Remittance Advice Remark Code N657: This should be billed with the appropriate code for these services."   Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   Non-covered Diagnosis   For PILD claims with procedure code 0275T with dates of service on or after January 9, 2014, or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD for LSS claims only when billed with the ICD -9 diagnosis of 724.01- 724.03 or the ICD -10 diagnosis of M48.05- M48.07.  The following messages shall be used when Medicare contractors return PILD claims, billed without the covered diagnosis, as unprocessable:   Claims Adjustment Reason Code B22:  This payment is adjusted based on the diagnosis.   Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   Clinical Trial Diagnosis   For PILD claims with procedure code 0275T with dates of service on or after January 9, 2014, or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD only when billed with the ICD -9 diagnosis of V70.7 (ICD -9) or Z00.6 (ICD -10) in either the primary or secondary positions.  The following messages shall be used when Medicare contractors return PILD claims, billed without the clinical trial diagnosis, as unprocessable:   Claims Adjustment Reason Code B22:  This payment is adjusted based on the diagnosis.   Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   330.2 - Claims Processing Requirements for PILD for Outpatient Facilities  (Rev. 3811, Issued: 07- 25-17, Effective: 12 -07-16, Implementation: 06- 27-17)   Hospital Outpatient facilities shall bill for percutaneous image -guided lumbar decompression (PILD) procedure code 0275T effective on or after January 9, 2014, or procedure code G0276 effective on or after January 1, 2015, for lumbar spinal stenosis (LSS) on a  13X or 85X TOB.  Refer to Section 69 of this chapter for further guidance on billing under CED.   Effective for dates of service on or after December 7, 2016, Medicare will cover PILD under CED for beneficiaries with LSS who are enrolled in a CMS -approved prospective longitudinal study for PILD procedures using a FDA -approved/cleared device that comple ted a CMS -approved randomized, controlled clinical trial (RCT) that met the criteria listed in the January 2014 NCD (see CR 8757, transmittal # 2959, dated May 16, 2014).    Hospital outpatient procedures for PILD shall be covered when billed with:    ICD-9 V70.7 (ICD -10 Z00.6) and Condition Code 30.  Modifier Q0   An 8 -digit clinical trial identifier number listed on the CMS Coverage with Evidence Development website   Hospital outpatient procedures for PILD shall be rejected when billed without:    ICD-9 V70.7 (ICD -10 Z00.6) and Condition Code 30.  Modifier Q0   An 8 -digit clinical trial identifier number listed on the CMS Coverage with Evidence Development website   Claims billed by hospitals not participating in the trial /registry, shall be rejected with the following message:   CARC: 50 - These are non -covered services because this is not deemed a medical necessity by the payer.   RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.  Group Code Contractual Obligation (CO)  MSN 16.77  This service/item was not covered because it was not provided as part of a qualifying trial/study. (Este servicio/artculo no fue cubierto porque no estaba incluido como parte de un ensayo clnico/estudio calificado.)  340  Transcatheter Edge -to-Edge Repair (TEER) for Mitral Valve Regurgitation  (Rev.  10985; Issued:09-08-21, Effective:01-19- 21; Implementation:10 -08-21)   Transcatheter Edge- to-Edge Repair (TEER) of the mitral valve (previously named Transcatheter Mitral Valve Repair (TMVR)) is used in the treatment of mitral regurgitation (MR).  TEER approximates the anterior and posterior mitral valve leaflets by grasping them with a clipping device in an approach similar to a treatment developed in cardiac surgery called the Alfieri stitch.