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