Local Coverage Article Billing and Coding

Billing and Coding: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

A58075

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Article Information

General Information

Article ID
A58075
Article Title
Billing and Coding: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
Article Type
Billing and Coding
Original Effective Date
06/21/2020
Revision Effective Date
01/01/2022
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 20 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) 

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

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea L38276.

General Guidelines for Claims submitted for Part A or Part B Services: 

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, Part A MAC systems will automatically deny the services.

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.

‎If the service is statutorily non-covered or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny. 

New implantation of a Hypoglossal Nerve Stimulator (HNS) for treatment of OSA code: 

  • CPT® code 64582 - Insertion of hypoglossal nerve stimulator electrode and generator and breathing sensor electrode. 

Revision or replacement during the life cycle of HNS components for treatment of OSA is reported with one or more of the following (as applicable):

  • CPT® code 64583 - Revision or replacement of hypoglossal nerve stimulator electrode and breathing sensor electrode with connection to existing generator *
  • CPT® code 61886 - (For a generator replacement): Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays
  • CPT® code 61888 - (For a generator revision): Revision or removal of cranial neurostimulator pulse generator or receiver

* Append modifier 52 in instances where only a portion of the device listed in the description is revised (e.g., revision of breathing sensor lead only or revision of stimulation lead only)

Removal of component(s) of a HNS for treatment of OSA is reported with one or more of the following (as applicable):

  • CPT® code 64584 - Removal of hypoglossal nerve neurostimulator electrode and generator and breathing sensor electrode *

* Append modifier 52 in instances where only a portion of the device listed in the description is revised (e.g., removal of generator only or both generator and stimulation lead or breathing sensor lead only or stimulation lead only)

Documentation Requirements 

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the Coverage Indications, Limitations and/or Medical Necessity section within the related LCD. This documentation includes, but is not limited to, appropriate use criteria, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. 

The patient’s medical record must document all of the following:

  • Symptoms
  • Polysomnography reporting
  • Drug Induced Sleep Endoscopy (DISE) reporting-CPT code 42975
  • Body mass index  

Replacement or revision of an implanted neurostimulator pulse generator system (with or without lead changes) for hypoglossal nerve stimulation is considered medically necessary in an individual when the implantation occurred because the LCD coverage criteria were met.

Utilization Guidelines 

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. 

Coding Information

CPT/HCPCS Codes

Group 1

(5 Codes)
Group 1 Paragraph

Note: CPT® codes related to component(s) removal, replacement or revision do not require a dual diagnosis.

Group 1 Codes
CodeDescription
61886 Implant neurostim arrays
61888 Revise/remove neuroreceiver
64582 Opn mpltj hpglsl nstm ary pg
64583 Rev/rplct hpglsl nstm ary pg
64584 Rmvl hpglsl nstim ary pg

CPT/HCPCS Modifiers

Group 1

(5 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
52 REDUCED SERVICES: UNDER CERTAIN CIRCUMSTANCES A SERVICE OR PROCEDURE IS PARTIALLY REDUCED OR ELIMINATED AT THE PHYSICIAN'S DISCRETION. UNDER THESE CIRCUMSTANCES THE SERVICE PROVIDED CAN BE IDENTIFIED BY ITS USUAL PROCEDURE NUMBER AND THE ADDITION OF THE MODIFIER -52, SIGNIFYING THAT THE SERVICE IS REDUCED. THIS PROVIDES A MEANS OF REPORTING REDUCED SERVICES WITHOUT DISTURBING THE IDENTIFICATION OF THE BASIC SERVICE. MODIFIER CODE 09952 MAY BE USED AS AN ALTERNATIVE TO MODIFIER -52. NOTE: FOR HOSPITAL OUTPATIENT REPORTING OF A PREVIOUSLY SCHEDULED PROCEDURE/SERVICE THAT IS PARTIALLY REDUCED OR CANCELLED AS A RESULT OF EXTENUATING CIRCUMSTANCES OR THOSE THAT THREATEN THE WELL-BEING OF THE PATIENT PRIOR TO OR AFTER ADMINISTRATION OF ANESTHESIA, SEE MODIFIERS -73 AND -74 (SEE MODIFIERS APPROVED FOR ASC HOSPITAL OUTPATIENT USE).
GA WAIVER OF LIABILITY STATEMENT ISSUED AS REQUIRED BY PAYER POLICY, INDIVIDUAL CASE
GX NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY
GY ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT
GZ ITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE AND NECESSARY

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

Use of these codes does not guarantee reimbursement. The patient’s medical record must document that the coverage criteria in the related LCD have been met.

Dual diagnosis requirement

Coverage for new insertion of a hypoglossal nerve stimulation device on patients who meet coverage criteria set forth in LCD L38276 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 Body Mass Index (BMI) is less than 35 kg/m2 as set forth in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD.

Report a primary diagnosis code from ICD-10 Codes that Support Medical Necessity Group 1: Codes and a secondary diagnosis code from ICD-10 Codes that Support Medical Necessity Group 2: Codes

Medicare is establishing the following limited coverage for CPT® code 64582

Primary Diagnosis

Group 1 Codes
CodeDescription
G47.33 Obstructive sleep apnea (adult) (pediatric)

Group 2

(16 Codes)
Group 2 Paragraph

Secondary Diagnosis

Group 2 Codes
CodeDescription
Z68.1 Body mass index [BMI] 19.9 or less, adult
Z68.20 Body mass index [BMI] 20.0-20.9, adult
Z68.21 Body mass index [BMI] 21.0-21.9, adult
Z68.22 Body mass index [BMI] 22.0-22.9, adult
Z68.23 Body mass index [BMI] 23.0-23.9, adult
Z68.24 Body mass index [BMI] 24.0-24.9, adult
Z68.25 Body mass index [BMI] 25.0-25.9, adult
Z68.26 Body mass index [BMI] 26.0-26.9, adult
Z68.27 Body mass index [BMI] 27.0-27.9, adult
Z68.28 Body mass index [BMI] 28.0-28.9, adult
Z68.29 Body mass index [BMI] 29.0-29.9, adult
Z68.30 Body mass index [BMI] 30.0-30.9, adult
Z68.31 Body mass index [BMI] 31.0-31.9, adult
Z68.32 Body mass index [BMI] 32.0-32.9, adult
Z68.33 Body mass index [BMI] 33.0-33.9, adult
Z68.34 Body mass index [BMI] 34.0-34.9, adult

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

Group 1

Group 1 Paragraph

All those not listed under the ICD-10 Codes that Support Medical Necessity section of this policy.

Group 1 Codes

N/A

ICD-10-PCS Codes

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.

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.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2022 R4

Under Article Text revised bulleted descriptions of CPT® codes and the explanation for the use of modifiers. Formatting was adjusted and acronyms were defined throughout the article where applicable. Under CPT/HCPCS Codes Group 1: Codes added codes 64582, 64583 and 64584, and deleted codes 64568, 64569, 64570, 0466T, 0467T, and 0468T. Under CPT/HCPCS Modifiers Group 1: Codes added modifier 52. Under ICD-10-CM Codes that Support Medical Necessity Group 1: Paragraph revised verbiage to support annual CPT/HCPCS code revisions. This revision is due to the Annual CPT/HCPCS update and is effective on 1/1/22.

10/01/2021 R3

Under ICD-10 Codes that Support Medical Necessity Group 2: Codes the description was revised for code Z68.30. This revision is due to the Annual ICD-10 update and is effective on 10/1/21.

10/01/2020 R2

Under Covered ICD-10 Codes Group 2: Codes the description was revised for codes Z68.1, Z68.20, Z68.21, Z68.22, Z68.23, Z68.24, Z68.25, Z68.26, Z68.27, Z68.28, Z68.29, Z68.30, Z68.31, Z68.32, Z68.33, and Z68.34. This revision is due to the Annual ICD-10 Code Update and is effective on 10/1/20.

06/21/2020 R1

Under Article Text General Guidelines for Claims submitted for Part A or Part B Services added verbiage to eleventh paragraph to read “New implantation of a Hypoglossal Nerve Stimulator (HNS) for treatment of OSA utilizes 2 CPT® codes:”. Under Article Text Revision or replacement added verbiage to subheading to read “Revision or replacement during the life cycle of HNS components for treatment of OSA is reported with one or more of the following (as applicable)”. Under Article Text Revision or replacement added CPT® codes 64569, 61886, and 61888 with descriptions. Under Article Text Removal added verbiage to subheading to read “Removal of component(s) of a HNS for treatment of OSA is reported with one or more of the following (as applicable)”. Under Article Text Removal added CPT® codes 64570 and 61888 with descriptions. Under Article Text Documentation Requirements added verbiage to read “Replacement or revision of an implanted neurostimulator pulse generator system (with or without lead changes) for hypoglossal nerve stimulation is considered medically necessary in an individual when the implantation occurred because the LCD coverage criteria were met”. Under CPT/HCPCS Codes Group 1: Paragraph added verbiage to subheading Note to read “CPT® codes related to component(s) removal, replacement or revision do not require a dual diagnosis”. Under CPT/HCPCS Codes Group1: Codes added 61886 and 61888. Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph Dual diagnosis requirement added verbiage to read “Coverage for new insertion of a hypoglossal nerve stimulation device on patients who meet coverage criteria set forth in LCD L38276 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 Body Mass Index (BMI) is less than 35 kg/m2 as set forth in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD” removed verbiage “and for 0467T” from third paragraph. Formatting and typographical errors were corrected throughout the LCD.

Associated Documents

Related National Coverage Documents
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
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Keywords

  • Hypoglossal
  • Nerve Stimulation
  • Obstructive Sleep Apnea