SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Spinal Cord Stimulation (Dorsal Column Stimulation)

A57023

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
Superseded
To see the currently-in-effect version of this document, go to the section.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57023
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Spinal Cord Stimulation (Dorsal Column Stimulation)
Article Type
Billing and Coding
Original Effective Date
09/26/2019
Revision Effective Date
09/26/2019
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Refer to as Local Coverage Determination (LCD) L35450, Spinal Cord Stimulation (Dorsal Column Stimulation)

Article Guidance

Article Text

Refer to the Novitas LCD L35450, Spinal Cord Stimulation (Dorsal Column Stimulation), for reasonable and necessary requirements and frequency limitations.

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

Generally, CPT codes 95970, 95971, and 95972 should not be reported at a frequency more often than once every 30 days. Refer to the related LCD for additional information.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
013x Hospital Outpatient
083x Ambulatory Surgery Center
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
036X Operating Room Services - General Classification
N/A

CPT/HCPCS Codes

Group 1

(3 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Note: The following CPT/HCPCS codes associated with the services outlined in this policy will not have diagnosis limitations applied at this time: 63661, 63662, 63663, 63664, 95970, 95971, 95972, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689, L8695 and L8699.

Group 1 Codes
Code Description
63650 Implant neuroelectrodes
63655 Implant neuroelectrodes
63685 Insrt/redo spine n generator
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(4 Codes)
Group 1 Paragraph

Note: It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Dual diagnosis requirement: Claims submitted for spinal cord stimulation must include both a primary ICD-10-CM diagnosis code indicating the reason for the procedure and a secondary ICD-10-CM diagnosis code indicating the etiology of the chronic pain.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 63650, 63655 and 63685:

Primary Diagnosis Codes

Group 1 Codes
Code Description
G89.21 Chronic pain due to trauma
G89.28 Other chronic postprocedural pain
G89.3 Neoplasm related pain (acute) (chronic)
G89.4 Chronic pain syndrome

Group 2

(432 Codes)
Group 2 Paragraph

The following are required Secondary Diagnosis Codes for CPT/HCPCS codes 63650, 63655 and 63685:

Group 2 Codes
Code Description
B02.0 Zoster encephalitis
B02.22 Postherpetic trigeminal neuralgia
B02.29 Other postherpetic nervous system involvement
G03.9 Meningitis, unspecified
G54.0 Brachial plexus disorders
G54.1 Lumbosacral plexus disorders
G54.6 Phantom limb syndrome with pain
G54.7 Phantom limb syndrome without pain
G54.8 Other nerve root and plexus disorders
G55 Nerve root and plexus compressions in diseases classified elsewhere
G56.40 Causalgia of unspecified upper limb
G56.41 Causalgia of right upper limb
G56.42 Causalgia of left upper limb
G56.43 Causalgia of bilateral upper limbs
G56.80 Other specified mononeuropathies of unspecified upper limb
G56.81 Other specified mononeuropathies of right upper limb
G56.82 Other specified mononeuropathies of left upper limb
G56.83 Other specified mononeuropathies of bilateral upper limbs
G56.90 Unspecified mononeuropathy of unspecified upper limb
G56.91 Unspecified mononeuropathy of right upper limb
G56.92 Unspecified mononeuropathy of left upper limb
G56.93 Unspecified mononeuropathy of bilateral upper limbs
G57.70 Causalgia of unspecified lower limb
G57.71 Causalgia of right lower limb
G57.72 Causalgia of left lower limb
G57.73 Causalgia of bilateral lower limbs
G57.80 Other specified mononeuropathies of unspecified lower limb
G57.81 Other specified mononeuropathies of right lower limb
G57.82 Other specified mononeuropathies of left lower limb
G57.83 Other specified mononeuropathies of bilateral lower limbs
G57.90 Unspecified mononeuropathy of unspecified lower limb
G57.91 Unspecified mononeuropathy of right lower limb
G57.92 Unspecified mononeuropathy of left lower limb
G57.93 Unspecified mononeuropathy of bilateral lower limbs
G58.0 Intercostal neuropathy
G90.511 Complex regional pain syndrome I of right upper limb
G90.512 Complex regional pain syndrome I of left upper limb
G90.513 Complex regional pain syndrome I of upper limb, bilateral
G90.519 Complex regional pain syndrome I of unspecified upper limb
G90.521 Complex regional pain syndrome I of right lower limb
G90.522 Complex regional pain syndrome I of left lower limb
G90.523 Complex regional pain syndrome I of lower limb, bilateral
G90.529 Complex regional pain syndrome I of unspecified lower limb
G90.59 Complex regional pain syndrome I of other specified site
I70.221 Atherosclerosis of native arteries of extremities with rest pain, right leg
I70.222 Atherosclerosis of native arteries of extremities with rest pain, left leg
I70.223 Atherosclerosis of native arteries of extremities with rest pain, bilateral legs
I70.228 Atherosclerosis of native arteries of extremities with rest pain, other extremity
I70.229 Atherosclerosis of native arteries of extremities with rest pain, unspecified extremity
M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.24 Other spondylosis with radiculopathy, thoracic region
M47.25 Other spondylosis with radiculopathy, thoracolumbar region
M47.26 Other spondylosis with radiculopathy, lumbar region
M47.27 Other spondylosis with radiculopathy, lumbosacral region
M50.10 Cervical disc disorder with radiculopathy, unspecified cervical region
M50.11 Cervical disc disorder with radiculopathy, high cervical region
M50.121 Cervical disc disorder at C4-C5 level with radiculopathy
M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region
M51.14 Intervertebral disc disorders with radiculopathy, thoracic region
M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region
M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
M54.11 Radiculopathy, occipito-atlanto-axial region
M54.12 Radiculopathy, cervical region
M54.13 Radiculopathy, cervicothoracic region
M54.14 Radiculopathy, thoracic region
M54.15 Radiculopathy, thoracolumbar region
M54.16 Radiculopathy, lumbar region
M54.17 Radiculopathy, lumbosacral region
M54.30 Sciatica, unspecified side
M54.31 Sciatica, right side
M54.32 Sciatica, left side
M54.40 Lumbago with sciatica, unspecified side
M54.41 Lumbago with sciatica, right side
M54.42 Lumbago with sciatica, left side
M96.1 Postlaminectomy syndrome, not elsewhere classified
S14.0XXA - S14.0XXS Concussion and edema of cervical spinal cord, initial encounter - Concussion and edema of cervical spinal cord, sequela
S14.101A - S14.101S Unspecified injury at C1 level of cervical spinal cord, initial encounter - Unspecified injury at C1 level of cervical spinal cord, sequela
S14.102A - S14.102S Unspecified injury at C2 level of cervical spinal cord, initial encounter - Unspecified injury at C2 level of cervical spinal cord, sequela
S14.103A - S14.103S Unspecified injury at C3 level of cervical spinal cord, initial encounter - Unspecified injury at C3 level of cervical spinal cord, sequela
S14.104A - S14.104S Unspecified injury at C4 level of cervical spinal cord, initial encounter - Unspecified injury at C4 level of cervical spinal cord, sequela
S14.105A - S14.105S Unspecified injury at C5 level of cervical spinal cord, initial encounter - Unspecified injury at C5 level of cervical spinal cord, sequela
S14.106A - S14.106S Unspecified injury at C6 level of cervical spinal cord, initial encounter - Unspecified injury at C6 level of cervical spinal cord, sequela
S14.107A - S14.107S Unspecified injury at C7 level of cervical spinal cord, initial encounter - Unspecified injury at C7 level of cervical spinal cord, sequela
S14.108A - S14.108S Unspecified injury at C8 level of cervical spinal cord, initial encounter - Unspecified injury at C8 level of cervical spinal cord, sequela
S14.109A - S14.109S Unspecified injury at unspecified level of cervical spinal cord, initial encounter - Unspecified injury at unspecified level of cervical spinal cord, sequela
S14.111A - S14.111S Complete lesion at C1 level of cervical spinal cord, initial encounter - Complete lesion at C1 level of cervical spinal cord, sequela
S14.112A - S14.112S Complete lesion at C2 level of cervical spinal cord, initial encounter - Complete lesion at C2 level of cervical spinal cord, sequela
S14.113A - S14.113S Complete lesion at C3 level of cervical spinal cord, initial encounter - Complete lesion at C3 level of cervical spinal cord, sequela
S14.114A - S14.114S Complete lesion at C4 level of cervical spinal cord, initial encounter - Complete lesion at C4 level of cervical spinal cord, sequela
S14.115A - S14.115S Complete lesion at C5 level of cervical spinal cord, initial encounter - Complete lesion at C5 level of cervical spinal cord, sequela
S14.116A - S14.116S Complete lesion at C6 level of cervical spinal cord, initial encounter - Complete lesion at C6 level of cervical spinal cord, sequela
S14.117A - S14.117S Complete lesion at C7 level of cervical spinal cord, initial encounter - Complete lesion at C7 level of cervical spinal cord, sequela
S14.118A - S14.118S Complete lesion at C8 level of cervical spinal cord, initial encounter - Complete lesion at C8 level of cervical spinal cord, sequela
S14.119A - S14.119S Complete lesion at unspecified level of cervical spinal cord, initial encounter - Complete lesion at unspecified level of cervical spinal cord, sequela
S14.121A - S14.121S Central cord syndrome at C1 level of cervical spinal cord, initial encounter - Central cord syndrome at C1 level of cervical spinal cord, sequela
S14.122A - S14.122S Central cord syndrome at C2 level of cervical spinal cord, initial encounter - Central cord syndrome at C2 level of cervical spinal cord, sequela
S14.123A - S14.123S Central cord syndrome at C3 level of cervical spinal cord, initial encounter - Central cord syndrome at C3 level of cervical spinal cord, sequela
S14.124A - S14.124S Central cord syndrome at C4 level of cervical spinal cord, initial encounter - Central cord syndrome at C4 level of cervical spinal cord, sequela
S14.125A - S14.125S Central cord syndrome at C5 level of cervical spinal cord, initial encounter - Central cord syndrome at C5 level of cervical spinal cord, sequela
S14.126A - S14.126S Central cord syndrome at C6 level of cervical spinal cord, initial encounter - Central cord syndrome at C6 level of cervical spinal cord, sequela
S14.127A - S14.127S Central cord syndrome at C7 level of cervical spinal cord, initial encounter - Central cord syndrome at C7 level of cervical spinal cord, sequela
S14.128A - S14.128S Central cord syndrome at C8 level of cervical spinal cord, initial encounter - Central cord syndrome at C8 level of cervical spinal cord, sequela
S14.129A - S14.129S Central cord syndrome at unspecified level of cervical spinal cord, initial encounter - Central cord syndrome at unspecified level of cervical spinal cord, sequela
S14.131A - S14.131S Anterior cord syndrome at C1 level of cervical spinal cord, initial encounter - Anterior cord syndrome at C1 level of cervical spinal cord, sequela
S14.132A - S14.132S Anterior cord syndrome at C2 level of cervical spinal cord, initial encounter - Anterior cord syndrome at C2 level of cervical spinal cord, sequela
S14.133A - S14.133S Anterior cord syndrome at C3 level of cervical spinal cord, initial encounter - Anterior cord syndrome at C3 level of cervical spinal cord, sequela
S14.134A - S14.134S Anterior cord syndrome at C4 level of cervical spinal cord, initial encounter - Anterior cord syndrome at C4 level of cervical spinal cord, sequela
S14.135A - S14.135S Anterior cord syndrome at C5 level of cervical spinal cord, initial encounter - Anterior cord syndrome at C5 level of cervical spinal cord, sequela
S14.136A - S14.136S Anterior cord syndrome at C6 level of cervical spinal cord, initial encounter - Anterior cord syndrome at C6 level of cervical spinal cord, sequela
S14.137A - S14.137S Anterior cord syndrome at C7 level of cervical spinal cord, initial encounter - Anterior cord syndrome at C7 level of cervical spinal cord, sequela
S14.138A - S14.138S Anterior cord syndrome at C8 level of cervical spinal cord, initial encounter - Anterior cord syndrome at C8 level of cervical spinal cord, sequela
S14.139A - S14.139S Anterior cord syndrome at unspecified level of cervical spinal cord, initial encounter - Anterior cord syndrome at unspecified level of cervical spinal cord, sequela
S14.141A - S14.141S Brown-Sequard syndrome at C1 level of cervical spinal cord, initial encounter - Brown-Sequard syndrome at C1 level of cervical spinal cord, sequela
S14.142A - S14.142S Brown-Sequard syndrome at C2 level of cervical spinal cord, initial encounter - Brown-Sequard syndrome at C2 level of cervical spinal cord, sequela
S14.143A - S14.143S Brown-Sequard syndrome at C3 level of cervical spinal cord, initial encounter - Brown-Sequard syndrome at C3 level of cervical spinal cord, sequela
S14.144A - S14.144S Brown-Sequard syndrome at C4 level of cervical spinal cord, initial encounter - Brown-Sequard syndrome at C4 level of cervical spinal cord, sequela
S14.145A - S14.145S Brown-Sequard syndrome at C5 level of cervical spinal cord, initial encounter - Brown-Sequard syndrome at C5 level of cervical spinal cord, sequela
S14.146A - S14.146S Brown-Sequard syndrome at C6 level of cervical spinal cord, initial encounter - Brown-Sequard syndrome at C6 level of cervical spinal cord, sequela
S14.147A - S14.147S Brown-Sequard syndrome at C7 level of cervical spinal cord, initial encounter - Brown-Sequard syndrome at C7 level of cervical spinal cord, sequela
S14.148A - S14.148S Brown-Sequard syndrome at C8 level of cervical spinal cord, initial encounter - Brown-Sequard syndrome at C8 level of cervical spinal cord, sequela
S14.149A - S14.149S Brown-Sequard syndrome at unspecified level of cervical spinal cord, initial encounter - Brown-Sequard syndrome at unspecified level of cervical spinal cord, sequela
S14.151A - S14.151S Other incomplete lesion at C1 level of cervical spinal cord, initial encounter - Other incomplete lesion at C1 level of cervical spinal cord, sequela
S14.152A - S14.152S Other incomplete lesion at C2 level of cervical spinal cord, initial encounter - Other incomplete lesion at C2 level of cervical spinal cord, sequela
S14.153A - S14.153S Other incomplete lesion at C3 level of cervical spinal cord, initial encounter - Other incomplete lesion at C3 level of cervical spinal cord, sequela
S14.154A - S14.154S Other incomplete lesion at C4 level of cervical spinal cord, initial encounter - Other incomplete lesion at C4 level of cervical spinal cord, sequela
S14.155A - S14.155S Other incomplete lesion at C5 level of cervical spinal cord, initial encounter - Other incomplete lesion at C5 level of cervical spinal cord, sequela
S14.156A - S14.156S Other incomplete lesion at C6 level of cervical spinal cord, initial encounter - Other incomplete lesion at C6 level of cervical spinal cord, sequela
S14.157A - S14.157S Other incomplete lesion at C7 level of cervical spinal cord, initial encounter - Other incomplete lesion at C7 level of cervical spinal cord, sequela
S14.158A - S14.158S Other incomplete lesion at C8 level of cervical spinal cord, initial encounter - Other incomplete lesion at C8 level of cervical spinal cord, sequela
S14.159A - S14.159S Other incomplete lesion at unspecified level of cervical spinal cord, initial encounter - Other incomplete lesion at unspecified level of cervical spinal cord, sequela
S14.2XXA - S14.2XXS Injury of nerve root of cervical spine, initial encounter - Injury of nerve root of cervical spine, sequela
S14.3XXA - S14.3XXS Injury of brachial plexus, initial encounter - Injury of brachial plexus, sequela
S24.0XXA - S24.0XXS Concussion and edema of thoracic spinal cord, initial encounter - Concussion and edema of thoracic spinal cord, sequela
S24.101A - S24.101S Unspecified injury at T1 level of thoracic spinal cord, initial encounter - Unspecified injury at T1 level of thoracic spinal cord, sequela
S24.102A - S24.102S Unspecified injury at T2-T6 level of thoracic spinal cord, initial encounter - Unspecified injury at T2-T6 level of thoracic spinal cord, sequela
S24.103A - S24.103S Unspecified injury at T7-T10 level of thoracic spinal cord, initial encounter - Unspecified injury at T7-T10 level of thoracic spinal cord, sequela
S24.104A - S24.104S Unspecified injury at T11-T12 level of thoracic spinal cord, initial encounter - Unspecified injury at T11-T12 level of thoracic spinal cord, sequela
S24.109A - S24.109S Unspecified injury at unspecified level of thoracic spinal cord, initial encounter - Unspecified injury at unspecified level of thoracic spinal cord, sequela
S24.111A - S24.111S Complete lesion at T1 level of thoracic spinal cord, initial encounter - Complete lesion at T1 level of thoracic spinal cord, sequela
S24.112A - S24.112S Complete lesion at T2-T6 level of thoracic spinal cord, initial encounter - Complete lesion at T2-T6 level of thoracic spinal cord, sequela
S24.113A - S24.113S Complete lesion at T7-T10 level of thoracic spinal cord, initial encounter - Complete lesion at T7-T10 level of thoracic spinal cord, sequela
S24.114A - S24.114S Complete lesion at T11-T12 level of thoracic spinal cord, initial encounter - Complete lesion at T11-T12 level of thoracic spinal cord, sequela
S24.119A - S24.119S Complete lesion at unspecified level of thoracic spinal cord, initial encounter - Complete lesion at unspecified level of thoracic spinal cord, sequela
S24.131A - S24.131S Anterior cord syndrome at T1 level of thoracic spinal cord, initial encounter - Anterior cord syndrome at T1 level of thoracic spinal cord, sequela
S24.132A - S24.132S Anterior cord syndrome at T2-T6 level of thoracic spinal cord, initial encounter - Anterior cord syndrome at T2-T6 level of thoracic spinal cord, sequela
S24.133A - S24.133S Anterior cord syndrome at T7-T10 level of thoracic spinal cord, initial encounter - Anterior cord syndrome at T7-T10 level of thoracic spinal cord, sequela
S24.134A - S24.134S Anterior cord syndrome at T11-T12 level of thoracic spinal cord, initial encounter - Anterior cord syndrome at T11-T12 level of thoracic spinal cord, sequela
S24.139A - S24.139S Anterior cord syndrome at unspecified level of thoracic spinal cord, initial encounter - Anterior cord syndrome at unspecified level of thoracic spinal cord, sequela
S24.141A - S24.141S Brown-Sequard syndrome at T1 level of thoracic spinal cord, initial encounter - Brown-Sequard syndrome at T1 level of thoracic spinal cord, sequela
S24.142A - S24.142S Brown-Sequard syndrome at T2-T6 level of thoracic spinal cord, initial encounter - Brown-Sequard syndrome at T2-T6 level of thoracic spinal cord, sequela
S24.143A - S24.143S Brown-Sequard syndrome at T7-T10 level of thoracic spinal cord, initial encounter - Brown-Sequard syndrome at T7-T10 level of thoracic spinal cord, sequela
S24.144A - S24.144S Brown-Sequard syndrome at T11-T12 level of thoracic spinal cord, initial encounter - Brown-Sequard syndrome at T11-T12 level of thoracic spinal cord, sequela
S24.149A - S24.149S Brown-Sequard syndrome at unspecified level of thoracic spinal cord, initial encounter - Brown-Sequard syndrome at unspecified level of thoracic spinal cord, sequela
S24.151A - S24.151S Other incomplete lesion at T1 level of thoracic spinal cord, initial encounter - Other incomplete lesion at T1 level of thoracic spinal cord, sequela
S24.152A - S24.152S Other incomplete lesion at T2-T6 level of thoracic spinal cord, initial encounter - Other incomplete lesion at T2-T6 level of thoracic spinal cord, sequela
S24.153A - S24.153S Other incomplete lesion at T7-T10 level of thoracic spinal cord, initial encounter - Other incomplete lesion at T7-T10 level of thoracic spinal cord, sequela
S24.154A - S24.154S Other incomplete lesion at T11-T12 level of thoracic spinal cord, initial encounter - Other incomplete lesion at T11-T12 level of thoracic spinal cord, sequela
S24.159A - S24.159S Other incomplete lesion at unspecified level of thoracic spinal cord, initial encounter - Other incomplete lesion at unspecified level of thoracic spinal cord, sequela
S24.2XXA - S24.2XXS Injury of nerve root of thoracic spine, initial encounter - Injury of nerve root of thoracic spine, sequela
S34.01XA - S34.01XS Concussion and edema of lumbar spinal cord, initial encounter - Concussion and edema of lumbar spinal cord, sequela
S34.02XA - S34.02XS Concussion and edema of sacral spinal cord, initial encounter - Concussion and edema of sacral spinal cord, sequela
S34.101A - S34.101S Unspecified injury to L1 level of lumbar spinal cord, initial encounter - Unspecified injury to L1 level of lumbar spinal cord, sequela
S34.102A - S34.102S Unspecified injury to L2 level of lumbar spinal cord, initial encounter - Unspecified injury to L2 level of lumbar spinal cord, sequela
S34.103A - S34.103S Unspecified injury to L3 level of lumbar spinal cord, initial encounter - Unspecified injury to L3 level of lumbar spinal cord, sequela
S34.104A - S34.104S Unspecified injury to L4 level of lumbar spinal cord, initial encounter - Unspecified injury to L4 level of lumbar spinal cord, sequela
S34.105A - S34.105S Unspecified injury to L5 level of lumbar spinal cord, initial encounter - Unspecified injury to L5 level of lumbar spinal cord, sequela
S34.109A - S34.109S Unspecified injury to unspecified level of lumbar spinal cord, initial encounter - Unspecified injury to unspecified level of lumbar spinal cord, sequela
S34.111A - S34.111S Complete lesion of L1 level of lumbar spinal cord, initial encounter - Complete lesion of L1 level of lumbar spinal cord, sequela
S34.112A - S34.112S Complete lesion of L2 level of lumbar spinal cord, initial encounter - Complete lesion of L2 level of lumbar spinal cord, sequela
S34.113A - S34.113S Complete lesion of L3 level of lumbar spinal cord, initial encounter - Complete lesion of L3 level of lumbar spinal cord, sequela
S34.114A - S34.114S Complete lesion of L4 level of lumbar spinal cord, initial encounter - Complete lesion of L4 level of lumbar spinal cord, sequela
S34.115A - S34.115S Complete lesion of L5 level of lumbar spinal cord, initial encounter - Complete lesion of L5 level of lumbar spinal cord, sequela
S34.119A - S34.119S Complete lesion of unspecified level of lumbar spinal cord, initial encounter - Complete lesion of unspecified level of lumbar spinal cord, sequela
S34.121A - S34.121S Incomplete lesion of L1 level of lumbar spinal cord, initial encounter - Incomplete lesion of L1 level of lumbar spinal cord, sequela
S34.122A - S34.122S Incomplete lesion of L2 level of lumbar spinal cord, initial encounter - Incomplete lesion of L2 level of lumbar spinal cord, sequela
S34.123A - S34.123S Incomplete lesion of L3 level of lumbar spinal cord, initial encounter - Incomplete lesion of L3 level of lumbar spinal cord, sequela
S34.124A - S34.124S Incomplete lesion of L4 level of lumbar spinal cord, initial encounter - Incomplete lesion of L4 level of lumbar spinal cord, sequela
S34.125A - S34.125S Incomplete lesion of L5 level of lumbar spinal cord, initial encounter - Incomplete lesion of L5 level of lumbar spinal cord, sequela
S34.129A - S34.129S Incomplete lesion of unspecified level of lumbar spinal cord, initial encounter - Incomplete lesion of unspecified level of lumbar spinal cord, sequela
S34.131A - S34.131S Complete lesion of sacral spinal cord, initial encounter - Complete lesion of sacral spinal cord, sequela
S34.132A - S34.132S Incomplete lesion of sacral spinal cord, initial encounter - Incomplete lesion of sacral spinal cord, sequela
S34.139A - S34.139S Unspecified injury to sacral spinal cord, initial encounter - Unspecified injury to sacral spinal cord, sequela
S34.21XA - S34.21XS Injury of nerve root of lumbar spine, initial encounter - Injury of nerve root of lumbar spine, sequela
S34.22XA - S34.22XS Injury of nerve root of sacral spine, initial encounter - Injury of nerve root of sacral spine, sequela
S34.3XXA - S34.3XXS Injury of cauda equina, initial encounter - Injury of cauda equina, sequela
S34.4XXA - S34.4XXS Injury of lumbosacral plexus, initial encounter - Injury of lumbosacral plexus, sequela
T85.112A - T85.112S Breakdown (mechanical) of implanted electronic neurostimulator of spinal cord electrode (lead), initial encounter - Breakdown (mechanical) of implanted electronic neurostimulator of spinal cord electrode (lead), sequela
T85.113A - T85.113S Breakdown (mechanical) of implanted electronic neurostimulator, generator, initial encounter - Breakdown (mechanical) of implanted electronic neurostimulator, generator, sequela
T85.122A - T85.122S Displacement of implanted electronic neurostimulator of spinal cord electrode (lead), initial encounter - Displacement of implanted electronic neurostimulator of spinal cord electrode (lead), sequela
T85.123A - T85.123S Displacement of implanted electronic neurostimulator, generator, initial encounter - Displacement of implanted electronic neurostimulator, generator, sequela
T85.192A - T85.192S Other mechanical complication of implanted electronic neurostimulator of spinal cord electrode (lead), initial encounter - Other mechanical complication of implanted electronic neurostimulator of spinal cord electrode (lead), sequela
T85.193A - T85.193S Other mechanical complication of implanted electronic neurostimulator, generator, initial encounter - Other mechanical complication of implanted electronic neurostimulator, generator, sequela
Z45.42 Encounter for adjustment and management of neurostimulator
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(51 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
F30.10 Manic episode without psychotic symptoms, unspecified
F30.11 Manic episode without psychotic symptoms, mild
F30.12 Manic episode without psychotic symptoms, moderate
F30.13 Manic episode, severe, without psychotic symptoms
F30.2 Manic episode, severe with psychotic symptoms
F30.3 Manic episode in partial remission
F30.4 Manic episode in full remission
F30.8 Other manic episodes
F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified
F31.11 Bipolar disorder, current episode manic without psychotic features, mild
F31.12 Bipolar disorder, current episode manic without psychotic features, moderate
F31.13 Bipolar disorder, current episode manic without psychotic features, severe
F31.2 Bipolar disorder, current episode manic severe with psychotic features
F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified
F31.31 Bipolar disorder, current episode depressed, mild
F31.32 Bipolar disorder, current episode depressed, moderate
F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features
F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features
F31.60 Bipolar disorder, current episode mixed, unspecified
F31.61 Bipolar disorder, current episode mixed, mild
F31.62 Bipolar disorder, current episode mixed, moderate
F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features
F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features
F31.73 Bipolar disorder, in partial remission, most recent episode manic
F31.74 Bipolar disorder, in full remission, most recent episode manic
F31.75 Bipolar disorder, in partial remission, most recent episode depressed
F31.76 Bipolar disorder, in full remission, most recent episode depressed
F31.77 Bipolar disorder, in partial remission, most recent episode mixed
F31.78 Bipolar disorder, in full remission, most recent episode mixed
F31.81 Bipolar II disorder
F31.9 Bipolar disorder, unspecified
F32.0 Major depressive disorder, single episode, mild
F32.1 Major depressive disorder, single episode, moderate
F32.2 Major depressive disorder, single episode, severe without psychotic features
F32.3 Major depressive disorder, single episode, severe with psychotic features
F32.4 Major depressive disorder, single episode, in partial remission
F32.5 Major depressive disorder, single episode, in full remission
F32.89 Other specified depressive episodes
F32.9 Major depressive disorder, single episode, unspecified
F33.0 Major depressive disorder, recurrent, mild
F33.1 Major depressive disorder, recurrent, moderate
F33.2 Major depressive disorder, recurrent severe without psychotic features
F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms
F33.41 Major depressive disorder, recurrent, in partial remission
F33.42 Major depressive disorder, recurrent, in full remission
F33.9 Major depressive disorder, recurrent, unspecified
F34.1 Dysthymic disorder
F34.81 Disruptive mood dysregulation disorder
F34.89 Other specified persistent mood disorders
F39 Unspecified mood [affective] disorder
F43.21 Adjustment disorder with depressed mood
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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
013x Hospital Outpatient
083x Ambulatory Surgery Center
085x Critical Access Hospital
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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this Article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, for further guidance.


Code Description
036X Operating Room Services - General Classification
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Other Coding Information

Group 1

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
09/26/2019 R1

Article revised and published on 09/26/2019 to indicate the following ICD-10 codes have been added to the ICD-10 Codes that Support Medical Necessity Group 2 Codes for dates of service 7/23/2019 and after: T85.112 A-S, T85.113 A-S, T85.122 A-S, T85.123 A-S, T85.192 A-S and T85.193 A-S and Z45.42. Also, slight formatting changes have been made.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
NCDs
160.7 - Electrical Nerve Stimulators
SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
07/13/2023 09/26/2019 - 07/13/2023 Retired View
10/08/2021 09/26/2019 - N/A Superseded View
09/20/2019 09/26/2019 - N/A Superseded You are here
09/19/2019 09/26/2019 - N/A Superseded View

Keywords

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