LCD Reference Article Billing and Coding Article

Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence

A53359

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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.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A53359
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2024
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

N/A

Article Guidance

Article Text

Background
Sacral Nerve Stimulation for urinary incontinence is covered for the treatment of urinary urge incontinence, urge-frequency syndrome, and urinary retention by the CMS National Coverage Determination (NCD) 230.18, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf. Direct stimulation of the sacral nerve(s) via an electrode array implanted at the level of the sacrum is the only treatment modality covered by the NCD. In addition, Noridian will cover sacral nerve stimulation by the same modality for the treatment of fecal incontinence, effective March 1, 2012.

Indications and Limitations

Urinary Incontinence
Sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates. Both the test and the permanent implantation are covered.

The NCD describes the following limitations for coverage to all three conditions:
• Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.
• Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded.
• Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. Improvement is measured through voiding diaries.

Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.

Fecal Incontinence
Noridian will cover sacral nerve modulation/stimulation for fecal incontinence effective March 1, 2012, when all of the following criteria are met:

• Chronic fecal incontinence with greater than two incontinent episodes on average per week and duration of incontinence greater than six months or for more than twelve months after vaginal childbirth; AND
• Documented failure or intolerance to conventional therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment); AND
• A successful percutaneous test stimulation, defined as at least 50% sustained (more than one week) improvement in symptoms; AND
• Condition is not related to anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) and/or chronic inflammatory bowel disease; AND
• Incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury.

Sacral nerve modulation/stimulation is considered experimental, investigational and unproven for the treatment of chronic constipation or chronic pelvic pain.

Sources:
•Internet Only Manual (IOM) Medicare National Coverage Determination Manual, Publication 100-03, Section 230.18 Sacral Nerve Stimulation for Urinary Incontinence;
•Abrams P et al. Fourth International Consultation on Incontinence recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence;
Neurourol Urodyn. 2010; 29(1):213-40;
Annals of Surgery, March 2010, Vol 251, Number 3. Sacral Nerve Stimulation for Fecal Incontinence, Results of a 120-Patient Prospective Multicenter Study;
•Michelsen H, Thompson-Fawcett M, Lundy L, Krogh K, Laurberg S, Buntzen S;
•Six Year Experience with Sacral Nerve Stimulation for Fecal Incontinence;
Dis Colon Rectum. 2010; 53(4)414-421; Mowatt G, Glazener CMA, Jarrett M. Sacral nerve stimulation for fecal incontinence and constipation in adults (Review);
The Cochrane Library. 2009, Issue 1; National Institute for Health and Clinical Excellence. Fecal incontinence: the management of fecal incontinence in adults. NICE Clinical Guideline 49, June 2007;
•Trailblazer Health Enterprises, Local Coverage Determination for Sacral Nerve Stimulation – 4S-154AB-R9, Effective March 01, 2008








Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
011x Hospital Inpatient (Including Medicare Part A)
013x Hospital Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0272 Medical/Surgical Supplies and Devices - Sterile Supply
0274 Medical/Surgical Supplies and Devices - Prosthetic/Orthotic Devices
0275 Medical/Surgical Supplies and Devices - Pacemaker
0276 Medical/Surgical Supplies and Devices - Intraocular Lens
0278 Medical/Surgical Supplies and Devices - Other Implant
0279 Medical/Surgical Supplies and Devices - Other Supplies/Devices
0280 Oncology - General Classification
0289 Oncology - Other Oncology
0290 Durable Medical Equipment (other than renal) - General Classification
0360 Operating Room Services - General Classification
0510 Clinic - General Classification
0521 Freestanding Clinic - Clinic Visit by Member to RHC/FQHC
0624 Medical/Surgical Supplies and Devices - FDA Investigational Devices
0920 Other Diagnostic Services - General Classification
N/A

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

Covered CPT/HCPCS Codes:

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

(10 Codes)
Group 2 Paragraph

Ancillary Coding

Group 2 Codes
Code Description
64585 REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY
64590 INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER
64595 REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY
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)
L8680 IMPLANTABLE NEUROSTIMULATOR ELECTRODE, EACH
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

(20 Codes)
Group 1 Paragraph

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

Covered ICD-10-CM diagnosis codes for CPT/HCPCS codes 64561 and 64581

Group 1 Codes
Code Description
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
N36.44 Muscular disorders of urethra
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
R32 Unspecified urinary incontinence
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
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
011x Hospital Inpatient (Including Medicare Part A)
013x Hospital Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
085x Critical Access Hospital
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
0272 Medical/Surgical Supplies and Devices - Sterile Supply
0274 Medical/Surgical Supplies and Devices - Prosthetic/Orthotic Devices
0275 Medical/Surgical Supplies and Devices - Pacemaker
0276 Medical/Surgical Supplies and Devices - Intraocular Lens
0278 Medical/Surgical Supplies and Devices - Other Implant
0279 Medical/Surgical Supplies and Devices - Other Supplies/Devices
0280 Oncology - General Classification
0289 Oncology - Other Oncology
0290 Durable Medical Equipment (other than renal) - General Classification
0360 Operating Room Services - General Classification
0510 Clinic - General Classification
0521 Freestanding Clinic - Clinic Visit by Member to RHC/FQHC
0624 Medical/Surgical Supplies and Devices - FDA Investigational Devices
0920 Other Diagnostic Services - General Classification
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
01/01/2024 R10

HCPCS codes 0786T, 0787T, 0788T and 0789T were not intended to be added to Group 2 and have been removed.

01/01/2024 R9

Per CR13507 – adding HCPCS codes 0786T, 0787T, 0788T and 0789T to Group 2 CPT/HCPCS codes effective 1/1/2024.

01/01/2024 R8

1/1/2024 - Either the short and/or long code description was changed for the following code(s) Group 2. Please Note: Depending on which descriptor was used, there may not be any changes to the code display in this document:
64585 
64590 
64595 

01/01/2020 R7

Updated to indicate this article is not an LCD reference article.

01/01/2020 R6

Removed broken link to CR11655

01/01/2020 R5

Article converted to Billing and Coding. No change is coverage was made.

01/01/2020 R4

Added C1820 to the Group 2 Ancillary Codes per CR 11655 linked below.

02/28/2019 R3

Remove this rev history when next approved. MCD bug and the wrong rev history recorded. This revision adds back 3/2/19 annual review date as well as 3/2/18 annual review date since that version was deleted.

02/28/2019 R2

This article is revised to add Type of Bill (TOB) and Revenue codes in the Bill Type Codes and Revenue Codes fields and CPT codes 64585 and 64595 to the Ancillary Codes in the Group 2 Codes as indicated in the Internet Only Manual (IOM) Claims Processing Manual,, Publication 100-4 Chapter 32, Section 40.2-40.5.

10/01/2016 R1 The article was revised to add the following diagnoses effective 10/1/2016: N39.492, R39.191 and R39.192. R39.11 is added effective 10/1/2015. The JEA article A53358 is retired and JEA contract numbers are added to this JEB coverage article.
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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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
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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
01/26/2024 01/01/2024 - N/A Currently in Effect You are here
01/18/2024 01/01/2024 - N/A Superseded View
12/19/2023 01/01/2024 - N/A Superseded View
11/14/2023 01/01/2020 - 12/31/2023 Superseded View
12/21/2022 01/01/2020 - N/A Superseded View
09/29/2020 01/01/2020 - N/A Superseded View
03/11/2020 01/01/2020 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Sacral Nerve
  • Stimulation
  • Incontinence
  • constipation
  • 64561
  • 64581
  • 64585
  • 64590
  • 64595
  • A4290
  • C1767
  • C1778
  • C1820
  • C1883
  • C1897
  • L8680