Local Coverage Article Billing and Coding

Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence

A59332

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Draft Article
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.

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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A59332
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence
Article Type
Billing and Coding
Original Effective Date
11/05/2023
Revision Effective Date
11/05/2023
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 2022 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.

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §40.1 Definition of a Global Surgical Package, §40.2 Billing Requirements for Global Surgeries, §40.3 Claims Review for Global Surgeries, §40.4 Adjudication of Claims for Global Surgeries

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, §40 Sacral Nerve Stimulation

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence L39543.

Note: Components of the Global Surgical Package includes miscellaneous services such as dressing changes; local incisional care; removal of cutaneous sutures and staples, lines, wires, tubes, drains.

Note: Minor Surgeries and Endoscopies, separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure are not allowed.

Services performed for any given diagnosis must meet all of the indications and limitations stated in the related LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

For CPT® 64561, no separate code may be added for fluoroscopic imaging, as this is included in the code.

For CPT® 64581, imaging guidance is not included, so it can be separately coded.

Group 1 Codes
Code Description
64561 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED
64581 OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT)

Group 2

(13 Codes)
Group 2 Paragraph

Ancillary Coding

Note: The “C” codes listed below are only applicable when billed under the hospital outpatient prospective payment system (OPPS) and they should be submitted in place of code A4290.

Group 2 Codes
Code Description
64585 REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY
64590 INSERTION OR REPLACEMENT OF PERIPHERAL OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING
64595 REVISION OR REMOVAL OF PERIPHERAL OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER
95970 ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH BRAIN, CRANIAL NERVE, SPINAL CORD, PERIPHERAL NERVE, OR SACRAL NERVE, NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, WITHOUT PROGRAMMING
95971 ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH SIMPLE SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL
95972 ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL
A4290 SACRAL NERVE STIMULATION TEST LEAD, EACH
C1767 GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE
C1778 LEAD, NEUROSTIMULATOR (IMPLANTABLE)
C1820 GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), WITH RECHARGEABLE BATTERY AND CHARGING SYSTEM
C1883 ADAPTER/EXTENSION, PACING LEAD OR NEUROSTIMULATOR LEAD (IMPLANTABLE)
C1897 LEAD, NEUROSTIMULATOR TEST KIT (IMPLANTABLE)
L8678 ELECTRICAL STIMULATOR SUPPLIES (EXTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATOR, PER MONTH
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

(19 Codes)
Group 1 Paragraph

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.

Group 1 Codes
Code Description
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
N32.81 Overactive bladder
N39.41 Urge incontinence
N39.42 Incontinence without sensory awareness
N39.46 Mixed incontinence
N39.490 Overflow incontinence
N39.492 Postural (urinary) incontinence
N39.498 Other specified urinary incontinence
R15.9 Full incontinence of feces
R33.0 Drug induced retention of urine
R33.8 Other retention of urine
R33.9 Retention of urine, unspecified
R35.0 Frequency of micturition
R39.11 Hesitancy of micturition
R39.14 Feeling of incomplete bladder emptying
R39.15 Urgency of urination
R39.191 Need to immediately re-void
R39.192 Position dependent micturition

Group 2

(44 Codes)
Group 2 Paragraph

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. 

Group 2 Codes
Code Description
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
N32.81 Overactive bladder
N39.41 Urge incontinence
N39.42 Incontinence without sensory awareness
N39.46 Mixed incontinence
N39.490 Overflow incontinence
N39.492 Postural (urinary) incontinence
N39.498 Other specified urinary incontinence
R15.9 Full incontinence of feces
R33.0 Drug induced retention of urine
R33.8 Other retention of urine
R33.9 Retention of urine, unspecified
R35.0 Frequency of micturition
R39.11 Hesitancy of micturition
R39.14 Feeling of incomplete bladder emptying
R39.15 Urgency of urination
R39.191 Need to immediately re-void
R39.192 Position dependent micturition
T85.111A Breakdown (mechanical) of implanted electronic neurostimulator of peripheral nerve electrode (lead), initial encounter
T85.111D Breakdown (mechanical) of implanted electronic neurostimulator of peripheral nerve electrode (lead), subsequent encounter
T85.111S Breakdown (mechanical) of implanted electronic neurostimulator of peripheral nerve electrode (lead), sequela
T85.113A Breakdown (mechanical) of implanted electronic neurostimulator, generator, initial encounter
T85.113D Breakdown (mechanical) of implanted electronic neurostimulator, generator, subsequent encounter
T85.113S Breakdown (mechanical) of implanted electronic neurostimulator, generator, sequela
T85.121A Displacement of implanted electronic neurostimulator of peripheral nerve electrode (lead), initial encounter
T85.121D Displacement of implanted electronic neurostimulator of peripheral nerve electrode (lead), subsequent encounter
T85.121S Displacement of implanted electronic neurostimulator of peripheral nerve electrode (lead), sequela
T85.123A Displacement of implanted electronic neurostimulator, generator, initial encounter
T85.123D Displacement of implanted electronic neurostimulator, generator, subsequent encounter
T85.123S Displacement of implanted electronic neurostimulator, generator, sequela
T85.191A Other mechanical complication of implanted electronic neurostimulator of peripheral nerve electrode (lead), initial encounter
T85.191D Other mechanical complication of implanted electronic neurostimulator of peripheral nerve electrode (lead), subsequent encounter
T85.191S Other mechanical complication of implanted electronic neurostimulator of peripheral nerve electrode (lead), sequela
T85.193A Other mechanical complication of implanted electronic neurostimulator, generator, initial encounter
T85.193D Other mechanical complication of implanted electronic neurostimulator, generator, subsequent encounter
T85.193S Other mechanical complication of implanted electronic neurostimulator, generator, sequela
T85.732A Infection and inflammatory reaction due to implanted electronic neurostimulator of peripheral nerve, electrode (lead), initial encounter
T85.732D Infection and inflammatory reaction due to implanted electronic neurostimulator of peripheral nerve, electrode (lead), subsequent encounter
T85.732S Infection and inflammatory reaction due to implanted electronic neurostimulator of peripheral nerve, electrode (lead), sequela
T85.734A Infection and inflammatory reaction due to implanted electronic neurostimulator, generator, initial encounter
T85.734D Infection and inflammatory reaction due to implanted electronic neurostimulator, generator, subsequent encounter
T85.734S Infection and inflammatory reaction due to 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

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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
N/A

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.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation
11/05/2023 R1

Under CPT/HCPCS Codes Group 2: Codes deleted L8680.

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
10/24/2023 11/05/2023 - N/A Currently in Effect You are here
09/12/2023 11/05/2023 - N/A Superseded View

Keywords

  • Sacral Nerve Stimulation
  • Urinary Incontinence
  • Fecal Incontinence