Percutaneous Image-guided Lumbar Decompression (PILD)

on Tuesday, 13 June 2017. All News Items | Outpatient Services | Medicare Coverage

Sorting Out the Acronyms

There are a number of updates to the Local Coverage Determinations (LCDs) and Articles of the Medicare Administrative Contractors (MACs) this month. There are not many new policies, but a large number of draft policies. You can see the table at the end of this article for a summary of the LCD/article updates. Since there are not many new LCDs, our focus policy this month is an NCD concerning PILD for LSS as discussed in MLN Matters Article MM10089. That is a lot of acronyms – keep reading to sort out all these letter combinations.

Back in 2014, CMS approved a National Coverage Determination (NCD) that covers Percutaneous Image-guided Lumbar Decompression (PILD) for beneficiaries with lumbar spinal stenosis (LSS) when provided in a prospective, randomized, controlled clinical trial meeting certain conditions under coverage with evidence development (CED). CMS recently released a revision to this NCD that expands coverage of PILD for LSS under CED through a prospective longitudinal study that again must meet certain criteria listed in Section 150.13 of the NCD manual.

PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. PILD is proposed as a non-invasive procedure for treatment of symptomatic LSS unresponsive to conservative therapy. The procedure uses specially designed instruments and is performed under x-ray guidance to identify and monitor the compressed area via epiduragram.

Although the results of the earlier trials were inconclusive and there are evidentiary concerns, CMS opted to continue trials rather than issue a non-coverage decision. CMS’s reasoning for continuing and expanding the CED coverage is explained in the Decision Memo. In this memo, CMS states, “it is important to demonstrate longer term outcomes because lumbar spinal stenosis is often a chronic, progressive disease, and a minimally invasive intervention that produces durable improvements in health outcomes has been sought to avoid the need for invasive spinal surgery.” A prospective longitudinal study will answer questions concerning longer term outcomes, such as subsequent invasive spinal procedures (e.g., surgery), potential harms of the procedure and pain medication usage. Continuing coverage under CED will allow continued patient access and support for innovation.

Therefore, per the NCD Transmittal, “Effective for dates of service on or after December 7, 2016, Medicare will cover PILD under CED for beneficiaries with LSS who are enrolled in a CMS-approved prospective longitudinal study PILD procedures using an FDA-approved/cleared device that completed a CMS-approved random clinical trial that met the criteria listed in the January 2014 NCD (see CR 8757, transmittal # 2959, dated May 16, 2014).” Because this is an expansion of coverage, the current coding and billing instructions remain the same.

These coding and billing instructions for PILD can be found in the Medicare Claims Processing Manual, Chapter 32. Section 330.2 addresses outpatient facility coding and billing requirements (such as in an outpatient hospital setting). An institutional claim for PILD must include the following:

  • Procedure code 0275T for a non-blinded trial or HCPCS code G0276 for a blinded trial,
  • Covered diagnosis code ICD-10 Z00.6 (ICD-9 V70.7),
  • Condition Code 30 on the claim,
  • Modifier Q0 appended to the procedure code, and
  • An 8-digit clinical trial identifier number found on the CMS Coverage with Evidence Development website.

The updated LCDs and Articles from the last month are listed below.

Cahaba JJ

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L34259 Drugs and Biologicals: Palonosetron HCL Injection (Aloxi ™) 10/1/2015 10/1/2015 5/5/2017 5/5/2017 Retired

 

CGS J15

IDTitleComment Start DateComment End DateFinalStatus
DL37254 Chiropractic Services 6/21/2017 8/5/2017 No Draft
DL37362 MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 6/21/2017 8/4/2017 No Draft
DL36910 MolDX: APC and MUTYH Gene Testing 6/21/2017 8/5/2017 No Draft
DL37356 MolDX: EndoPredict Breast Cancer Gene Expression Test 6/21/2017 8/4/2017 No Draft
DL37364 MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) 6/21/2017 8/4/2017 No Draft
DL37348 MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels 6/21/2017 8/4/2017 No Draft
DL37354 MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 6/21/2017 8/4/2017 No Draft
DL37352 MolDX: Prometheus IBD sgi Diagnostic Policy 6/21/2017 8/4/2017 No Draft
DL36908 MolDX-CDD: Percepta© Bronchial Genomic Classifier 6/21/2017 8/5/2017 No Draft

 

First Coast JN

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L34020 Sargramostim (GM-CSF, Leukine ®) 10/1/2015 N/A 5/10/2017 5/10/2017 Retired
L33708 Plerixafor (Mozobil ®) 10/1/2015 1/1/2016 5/10/2017 5/11/2017 Retired
L33596 Qutenza® (capsaicin) 8% patch 10/1/2015 10/1/2015 5/10/2017 5/11/2017 Retired
L34000 Ganciclovir and Cidofovir 10/1/2015 10/1/2015 5/10/2017 5/10/2017 Retired
L33987 Computerized Dynamic Posturography 10/1/2015 N/A 5/10/2017 5/11/2017 Retired
L33377 Implantable Miniature Telescope (IMT) 10/1/2015 10/1/2016 5/10/2017 5/10/2017 Retired
IDTitleComment Start DateComment End DateFinalStatus
DL37398 Electroretinography (ERG) 5/18/2017 7/6/2017 No Draft
DL37404 Lower Extremity Revascularization 5/18/2017 7/6/2017 No Draft

 

NGS J6 and JK

IDTitleComment Start DateComment End DateFinalStatus
DL36904 Cognitive Rehabilitation 6/19/2017 8/2/2017 No Draft
DL35080 Endoscopic Treatment of GERD 6/19/2017 8/2/2017 No Draft
DL37078 Genomic Sequence Analysis Panels in the Treatment of Myelodysplastic Syndromes (MDS) 6/19/2017 8/2/2017 No Draft
DL37244 Micro-Invasive Glaucoma Surgery (MIGS) 6/19/2017 8/2/2017 No Draft
DL33575 Varicose Veins of the Lower Extremity, Treatment of 6/19/2017 8/2/2017 No Draft

 

Noridian JE

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L36861 Polysomnography and Other Sleep Studies 6/5/2017 N/A N/A 3/29/2017 New
L36704 MolDX- CDD: ProMark Risk Score 6/1/2017 N/A N/A 3/21/2017 New
L36678 Bladder/Urothelial Tumor Markers 5/16/2017 N/A N/A 3/16/2017 New
L36886 MolDX-CDD: Percepta© Bronchial Genomic Classifier 5/15/2017 N/A N/A 3/17/2017 New
L36882 MolDX: APC and MUTYH Gene Testing 5/15/2017 N/A N/A 3/17/2017 New
IDTitleComment Start DateComment End DateFinalStatus
DL34313 Allergy Testing 6/1/2017 8/14/2017 No Draft
DL34242 Chiropractic Services 6/1/2017 8/14/2017 No Draft
DL37309 Duplex Scan Of Lower Extremity Arteries 6/1/2017 8/14/2017 No Draft
DL34315 Electrocardiograms 6/1/2017 8/14/2017 No Draft
DL34220 Lumbar MRI 6/1/2017 8/14/2017 No Draft
DL37303 MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 6/1/2017 8/14/2017 No Draft
DL37295 MolDX: EndoPredict® Breast Cancer Gene Expression Test 6/1/2017 8/14/2017 No Draft
DL37350 MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) 6/1/2017 8/14/2017 No Draft
DL37301 MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels 6/1/2017 8/14/2017 No Draft
DL37305 MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 6/1/2017 8/14/2017 No Draft
DL37299 MolDX: Prometheus IBD sgi Diagnostic Policy 6/1/2017 8/14/2017 No Draft
DL37272 Monitored Anesthesia Care (MAC) 6/1/2017 8/14/2017 No Draft
DL37373 MRI and CT Scans of the Head and Neck 6/1/2017 8/14/2017 No Draft
DL37317 Noninvasive Extracranial Arterial Studies 6/1/2017 8/14/2017 No Draft
DL34229 Noninvasive Peripheral Venous Studies 6/1/2017 8/14/2017 No Draft
DL37307 Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries 6/1/2017 8/14/2017 No Draft
DL34328 Peripheral Nerve Stimulation 6/1/2017 8/14/2017 No Draft
DL34247 Pulmonary Function Testing 6/1/2017 8/14/2017 No Draft
DL34149 Respiratory Care (Respiratory Therapy ) 6/1/2017 8/14/2017 No Draft
DL37319 Transcranial Doppler Studies 6/1/2017 8/14/2017 No Draft

 

Noridian JF

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L36706 MolDX-CDD: ProMark Risk Score 6/1/2017 N/A N/A 3/21/2017 New
L36859 Trigger Point Injections 5/26/2017 N/A N/A 3/23/2017 New
L36680 Bladder/Urothelial Tumor Markers 5/16/2017 N/A N/A 3/16/2017 New
L36884 MolDX: APC and MUTYH Gene Testing 5/15/2017 N/A N/A 3/17/2017 New
L36891 MolDX-CDD: Percepta© Bronchial Genomic Classifier 5/15/2017 N/A N/A 3/17/2017 New
IDTitleComment Start DateComment End DateFinalStatus
DL37342 Allergy Testing 6/1/2017 8/14/2017 No Draft
DL34009 Chiropractic Services 6/1/2017 8/14/2017 No Draft
DL37340 Duplex Scan Of Lower Extremity Arteries 6/1/2017 8/14/2017 No Draft
DL37283 Electrocardiograms 6/1/2017 8/14/2017 No Draft
DL37281 Lumbar MRI 6/1/2017 8/14/2017 No Draft
DL37358 MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 6/1/2017 8/14/2017 No Draft
DL37311 MolDX: EndoPredict® Breast Cancer Gene Expression Test 6/1/2017 8/14/2017 No Draft
DL37368 MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) 6/1/2017 8/14/2017 No Draft
DL37315 MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels 6/1/2017 8/14/2017 No Draft
DL37321 MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 6/1/2017 8/14/2017 No Draft
DL37313 MolDX: Prometheus IBD sgi Diagnostic Policy 6/1/2017 8/14/2017 No Draft
DL34100 Monitored Anesthesia Care (MAC) 6/1/2017 8/14/2017 No Draft
DL35175 MRI and CT Scans of the Head and Neck 6/1/2017 8/14/2017 No Draft
DL37344 Noninvasive Extracranial Arterial Studies 6/1/2017 8/14/2017 No Draft
DL37291 Noninvasive Peripheral Venous Studies 6/1/2017 8/14/2017 No Draft
DL37336 Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries 6/1/2017 8/14/2017 No Draft
DL37360 Peripheral Nerve Stimulation 6/1/2017 8/14/2017 No Draft
DL37289 Pulmonary Function Testing 6/1/2017 8/14/2017 No Draft
DL37293 Respiratory Care (Respiratory Therapy ) 6/1/2017 8/14/2017 No Draft
DL37346 Transcranial Doppler Studies 6/1/2017 8/14/2017 No Draft

 

Novitas JH and JL

IDTitleComment Start DateComment End DateFinalStatus
DL37371 Electroretinography (ERG) 5/18/2017 7/6/2017 No Draft
DL37375 Reflectance Confocal Microscopy 5/18/2017 7/6/2017 No Draft
DL35035 Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography 5/18/2017 7/6/2017 No Draft

 

Palmetto JM

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L36954 Noncovered Services other than CPT® Category III Noncovered Services 6/5/2017 6/5/2017 N/A 5/19/2017 New
IDTitleComment Start DateComment End DateFinalStatus
DL33423 Cardiac Computed Tomography & Angiography (CCTA) 6/5/2017 7/20/2017 No Draft
DL33428 Cosmetic and Reconstructive Surgery 6/5/2017 7/20/2017 No Draft
DL37379 Echocardiography 6/5/2017 7/20/2017 No Draft
DL37338 MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) 6/5/2017 7/20/2017 No Draft
DL34555 Non-Covered Category III CPT Codes 6/5/2017 7/20/2017 No Draft

 

WPS J5 and J8

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
A55532 MolDX: CYP2C9 and/or VKORC1 Gene Testing for Warfarin Response Coding and Billing Guidelines 7/17/2017 N/A N/A 5/15/2017 New

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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