(Medicare Claims Processing Manual)

The applicable bill types for test stimulation procedures are 13X, 71X, 73X, 75X and 85X.   The RHCs and FQHCs bill you under bill type 71X and 73X for the professional component. The technical component is outside the scope of the RHC/FQHC benefit. The provider of that technical service bills their A/B MAC (B) using the ASC X12 837 professional claim format or the Form CMS -1500.   The technical component for a provider -based RHC/FQHC is typically furnished by the provider. The provider of that service bills you under bill type 13X, or 85X as appropriate using their outpatient provider number (not the RHC/FQHC provider number since t hese services are not covered as RHC/FQHC services.) Effective 4/1/06, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for test stimulation procedures.   The applicable bill types for implantation procedures and devices are 11X, 13X, and 85X.   40.4  Revenue Codes  (Rev.10881; Issued: 08- 06-2021; Effective: 09- 07-2021; Implementation: 09- 07- 2021)   The applicable revenue code for the test procedures is 920 except for RHCs/FQHCs who  report these procedures under revenue code 521.   Revenue codes for the implantation can be performed in a number of revenue centers within a hospital such as operating room (360) or clinic (510). Therefore, instruct your hospitals to report these implantation procedures under the revenue center where they are performed.   The applicable revenue code for the device codes C1767, C1778, C1883, C1897, and C1820 provided in a hospital outpatient department is 272, 274, 275, 276, 278, 279, 280, 289, 290 or 624 as appropriate. The applicable revenue code for device codes A4290, E0752 and  E0756 provided in a CAH is 290.  40.5  Claims Editing  (Rev. 125, 03- 26-04)  Nationwide claims processing edits for pre or post payment review of claim(s) for sacral nerve stimulation are not being required at this time.  Contractors may develop local medical review policy and edits for such claim(s).   50  Deep Brain Stimulation for Essential Tremor and Parkinsons Disease  (Rev. 128, 03- 26-04)  Deep brain stimulation (DBS) refers to high- frequency electrical stimulation of anatomic regions deep within the brain utilizing neurosurgically implanted electrodes.  These DBS electrodes are stereotactically placed within targeted nuclei on one (unilateral) or both (bilateral) sides of the brain.  There are currently three targets for DBS -- the thalamic ventralis intermedius nucleus (VIM), subthalamic nuc leus (STN) and globus pallidus interna (GPi).   Essential tremor (ET) is a progressive, disabling tremor most often affecting the hands.  ET may also affect the head, voice and legs.  The precise pathogenesis of ET is unknown.  While it may start at any age, ET usually peaks within the second and sixth decades.  Beta-adrenergic blockers and anticonvulsant medications are usually the first line treatments for reducing the severity of tremor.  Many patients, however, do not adequately respond or cannot tolerate these medications.  In these medically refractory ET patients, thalamic VIM DBS may be helpful for symptomatic relief of tremor.   Parkinsons disease (PD) is an age -related progressive neurodegenerative disorder involving the loss of dopaminergic cells in the substantia nigra of the midbrain.  The disease is characterized by tremor, rigidity, bradykinesia and progressive postural ins tability.  Dopaminergic medication is typically used as a first line treatment for reducing the primary symptoms of PD.  However, after prolonged use, medication can become less effective and can produce significant adverse events such as dyskinesias and other motor function complications.  For patients who become unresponsive to medical treatments and/or ha ve intolerable side effects from medications, DBS for symptom relief may be considered.   50.1  Coverage Requirements  (Rev. 128, 03- 26-04)  Effective on or after April 1, 2003, Medicare will cover unilateral or bilateral thalamic VIM DBS for the treatment of ET and/or Parkinsonian tremor and unilateral or bilateral STN or GPi DBS for the treatment of PD only under the following conditions:   1. Medicare will only consider DBS devices to be reasonable and necessary if they are Food and Drug Administration (FDA) approved devices for DBS or devices used in accordance with FDA approved protocols governing Category B Investigational Device Exemptio n (IDE) DBS clinical trials.   2. For thalamic VIM DBS to be considered reasonable and necessary, patients must meet all of the following criteria:  a. Diagnosis of essential tremor (ET) based on postural or kinetic tremors of hand(s) without other neurologic signs, or diagnosis of idiopathic PD (presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia)) which is of a tremor - dominant  form.   b. Marked disabling tremor of at least level 3 or 4 on the Fahn- Tolosa -Marin Clinical Tremor Rating Scale (or equivalent scale) in the extremity intended for treatment, causing significant limitation in daily activities despite optimal medical therapy.   c. Willingness and ability to cooperate during conscious operative procedure, as well as during post -surgical evaluations, adjustments of medications and stimulator settings.   3. For STN or GPi DBS to be considered reasonable and necessary, patients must meet all of the following criteria:  a. Diagnosis of PD based on the presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia).   b. Advanced idiopathic PD as determined by the use of Hoehn and Yahr stage or Unified Parkinsons Disease Rating Scale (UPDRS) part III motor subscale.  c. L-dopa responsive with clearly defined on periods.  d. Persistent disabling Parkinsons symptoms or drug side effects (e.g., dyskinesias, motor fluctuations, or disabling off periods) despite optimal medical therapy.   e. Willingness and ability to cooperate during conscious operative procedure, as well as during post -surgical evaluations, adjustments of medications and stimulator settings.   The DBS is not reasonable and necessary and is not covered for ET or PD patients with any of the following:   1. Non-idiopathic Parkinsons disease or Parkinsons Plus syndromes.  2. Cognitive impairment, dementia or depression which would be worsened by or would interfere with the patients ability to benefit from DBS.   3. Current psychosis, alcohol abuse or other drug abuse.  4. Structural lesions such as basal ganglionic stroke, tumor or vascular malformation as etiology of the movement disorder.   5. Previous movement disorder surgery within the affected basal ganglion.  6. Significant medical, surgical, neurologic or orthopedic co- morbidities contraindicating DBS surgery or stimulation.  Patients who undergo DBS implantation should not be exposed to diathermy (deep heat treatment including shortwave diathermy, microwave diathermy and ultrasound diathermy) or any type of MRI which may adversely affect the DBS system or adversely affect the brain around the implanted electrodes.   The DBS should be performed with extreme caution in patients with cardiac pacemakers or other electronically controlled implants which may adversely affect or be affected by the DBS system.   For DBS lead implantation to be considered reasonable and necessary, providers and facilities must meet all of the following criteria:    1. Neurosurgeons must: (a) be properly trained in the procedure; (b) have experience with the surgical management of movement disorders, including DBS therapy; and (c) have experience performing stereotactic neurosurgical procedures    2. Operative teams must have training and experience with DBS systems, including knowledge of anatomical and neurophysiological characteristics for localizing the targeted nucleus, surgical and/or implantation techniques for the DBS system, and operationa l and functional characteristics of the device.    3. Physicians specializing in movement disorders must be involved in both patient selection and post -procedure care.    4. Hospital medical centers must have: (a) brain imaging equipment (MRI and/or CT) for pre -operative stereotactic localization and targeting of the surgical site(s); (b) operating rooms with all necessary equipment for stereotactic surgery; and (c) support  services necessary for care of patients undergoing this procedure and any potential complications arising intraoperatively or postoperatively.  50.2  Billing Requirements (Rev. 128, 03- 26-04)  50.2.1  Part A Intermediary Billing Procedures  (Rev. 128, 03- 26-04)  This procedure can be two fold.  Implantation of the electrodes is performed in a hospital inpatient setting.  Implantation of the pulse generator can be performed in an outpatient department.   50.3 - Payment Requirements  (Rev. 128, 03- 26-04)  50.3.1  Part A Payment Methods  (Rev. 128, 03- 26-04)  Payment for the inpatient procedure is under Diagnostic Related Group (DRG).  The outpatient procedure is outpatient prospective payment system.  For critical access hospitals (CAH), the inpatient stay is on reasonable cost and the outpatient procedures ar e also based on reasonable cost.   50.3.2  Bill Types (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Deep Brain Stimulation may be submitted on institutional claims using the following Types of Bill:   11X, 12X, 13X, and 85X   50.3.3  Revenue Codes (Rev. 128, 03- 26-04)  Revenue codes for implementation can be performed in a number of revenue centers within a hospital such as operating room (360) or clinic (510).  The codes to report the pulse generator and/or electrodes are 270, 278, 279.  For CAHs that choose method II, use revenue code 98X for the professional component only.  50.4  Allowable Codes  (Rev. 128, 03- 26-04)  50.4.1  Allowable Covered Diagnosis Codes (Rev. 12435, Issued:12- 28-23, Effective:01 -29-24, Implementation:01- 29-24) Deep Brain Stimulation is covered for the following diagnosis codes:  If ICD -10-CM is applicable:    ICD-10-CM G20.A1 -  Parkinson's disease without dyskinesia, without mention of fluctuations    ICD-10-CM G20.A2 -  Parkinson's disease without dyskinesia, with fluctuations    ICD-10-CM G20.B1 -  Parkinson's disease with dyskinesia, without mention of fluctuations    ICD-10 CM G20.B2 -  Parkinson's disease with dyskinesia, with fluctuations    ICD-10-CM G20.C -  Parkinsonism, unspecified   ICD-10-CM G25.0 - Essential  tremor   ICD-10-CM G25.2 - Other specified form of  tremor   50.4.2  Allowable Covered Procedure Codes  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)   The following procedure codes may be present:     If ICD -10-PCS is applicable: