Knowledge Base Article

Several years ago, our neighbor gave us a “stick” to plant. He said it was a fig tree. My husband and I were both doubtful this stick would ever become anything, let alone a fig tree. That fig tree is now about 12 feet around and 15 feet high, loaded with beautiful, sweet figs. It is so tall in fact that I have to have a ladder to gather the fruit growing up high. I often however, pick the low-hanging fruit as I pass by the tree. As well as the reality of my fig tree, “low-hanging fruit” is a saying for all easily obtained gains.

CMS quarterly publishes the Provider Compliance Newsletter about common billing errors and other erroneous activities related to Medicare Fee-for-Service (FFS) program. The newsletter provides examples of errors and offers tips on ways to avoid them. Articles identify the types of providers affected by the issues, such as physicians, non-physician practitioners, outpatient hospital, etc. as well as whether the errors were identified by the Comprehensive Error Rate Testing (CERT) program or by the Recovery Auditors (RACs). It is also not unusual for other types of Medicare reviewers, especially the Medicare Administrative Contractors (MACs), to select issues identified by the CERT or RACs for their medical review activities. High-risk issues can be easy “low-hanging fruit” for finding overpayments to recoup.

The July 2018 Medicare Quarterly Provider Compliance Newsletter includes an article related to outpatient hospital services concerning Medicare coverage of vagus nerve stimulation (VNS). This was at one time an issue being reviewed by the Recovery Auditors. Vagus Nerve Stimulation is a pulse generator,

surgically implanted under the skin of the left chest and connected to the left vagus nerve. Electrical signals sent from the battery-powered generator to the vagus nerve via the lead are in turn sent to the brain. VNS is used to treat certain types of epilepsy.

In July 1999, Medicare issued a National Coverage Determination (NCD) allowing coverage of VNS for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. The coverage is specifically limited to “partial onset” seizures and other types of seizures are not covered. In May 2007, CMS issued an additional non-coverage decision for the use of VNS for patients with resistant depression.

This means VNS is only covered for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. If you provide VNS for other types of seizures (not partial onset) or for resistant depression, Medicare will not cover the VNS. Specifically, one of the following diagnosis codes must be reported for Medicare to cover VNS:

• G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epileptic
• G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
• G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
• G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
• G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
• G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus

Outpatient hospitals need to have systems in place to verify VNS is being performed for an appropriate, covered indication for their Medicare patients. If VNS is used for non-covered indications, inform the patient with an Advance Beneficiary Notice (ABN) so the patient understands they are financially liable for payment. This will allow your facility to avoid being “low-hanging fruit” for recoupments.