Knowledge Base Article

I did not realize the extent of peripheral nerve stimulation procedures until I started reading all of the related Medicare coverage policies – there was so much information, it almost got on my last nerve. All peripheral nerve stimulation is not the same. This is evidenced by several new coverage, or more accurately, non-coverage articles this month from the Medicare Administrative Contractors (MACs). Below is a listing of the MAC local coverage determinations (LCDs) and coverage articles that address peripheral nerve stimulation. Some of the policies listed may have a future effective date due to recent changes in coverage. You can easily view these policies by going to the Medicare Coverage Database and entering the Policy number in the Quick Search ‘Document ID’ field. 

There are different indications for different types of peripheral nerve stimulation.

Peripheral Nerve Stimulation (PNS) for Chronic Pain

Quoting from the Noridian JE Peripheral Nerve Stimulation article:

“Peripheral nerve stimulation (PNS) may be covered for relief of chronic intractable pain for patients with conditions known to be responsive to this form of therapy, and only after attempts to cure the underlying conditions and appropriate attempts at medication management, physical therapy, psychological therapy and other less invasive interventional treatments….PNS refers to the placement of a lead by a physician (via open surgical or percutaneous approach) near the known anatomic location of a peripheral nerve.”

Coverage of PNS requires the patients have all of the following:

• Documented chronic and severe pain for at least 3 months,
• Documented failure of less invasive treatment modalities and medications,
• Lack of surgical contraindications including infections and medical risks,
• Appropriate proper patient education, discussion and disclosure of risks and benefits,
• No active substance abuse issues,
• Formal psychological screening by a mental health professional, and
• Successful stimulation trial with greater than or equal to 50% reduction in pain intensity before permanent implantation.

CPT codes for PNS addressed by the Noridian policy include: 61885, 64550, 64553, 64555, 64561, 64569, 64570, 64575, 64581, 64585, 64590, and 64595. Also see National Coverage Determination (NCD) 160.7 for other coverage information on Implanted Peripheral Nerve Stimulators.

Peripheral Nerve Stimulation for Urinary and/or Fecal Incontinence

Sacral nerve stimulation coverage for urinary and fecal incontinence is addressed by several MAC policies. Covered indications include:

• Urinary urge incontinence.
• Urgency-frequency syndrome.
• Urinary retention.
• Fecal incontinence.

There are limitations to coverage such as refractory or documented failure or intolerance to conventional therapy; only after a successful percutaneous test stimulation, defined as at least 50% improvement in symptoms; and the exclusion of certain causes of the incontinence. Limitations vary slightly per policy so providers should read carefully the policy which applies to their MAC jurisdiction. CPT codes 64561, 64581, and sometimes 64585 or 64590 are addressed by the Sacral nerve stimulation policies.

Posterior tibial nerve stimulation (CPT code 64566) is generally covered in a physician office setting for urinary urgency, urinary frequency, and urge incontinence. Patients receive one 30-minute weekly treatment in the office for 12 weeks, but most MACs allow treatments for a longer time to patients who demonstrate significant improvement in overactive bladder (OAB) symptoms. Most MACs require documentation of failed standard anticholinergic drug therapy or intolerance to the anticholinergic drug therapy. Again, requirements vary from MAC to MAC, so providers need to be aware of their MAC’s requirements.

Non-Covered Peripheral Nerve Stimulation

As stated at the beginning of this article, new coverage articles this month detail the correct coding and non-coverage of certain types of peripheral nerve stimulation. Remember, coverage for services not addressed by a national coverage determination or Medicare manuals is determined by the individual MACs. Not all MACs make the same coverage determinations. If coverage of a particular service is not addressed by an LCD or coverage article for your MAC, you will need to contact your MAC to determine if they cover the service or not.

The WPS article for Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT) explains that “PENS and PNT therapies combine the features of electroacupuncture and transcutaneous electrical nerve stimulation (TENS)…. PENS is performed with a few needle electrodes (not implanted) while PNT uses very fine needle-like electrode arrays (not implanted) that are placed in close proximity to the painful area to stimulate peripheral sensory nerves in the soft tissue.”

Per the WPS article, therapeutic use of these services is non-covered and should be reported with CPT code 64999 and the respective procedure name. They should not be reported with:

• CPT codes 64553-64566 as these apply to percutaneous implantation of neurostimulator electrodes and not appropriate, as PENS and PNT use percutaneously inserted needles, OR
• CPT code 64590 as this applies to insertion or replacement of neurostimulator pulse generator or receiver and not appropriate, as PENS and PNT stimulation devices are not implanted, OR
• HCPCS code range L8680-L8689.
• It would also not be appropriate for providers to use any neurostimulator pulse generator or receiver implantation CPT codes such as CPT 63663, 63685, 63688, 64585, 64590.

Specifically, Biowave’s Deepwave percutaneous neuromodulation pain therapy system is one PENS system that is non-covered. (See NCD 160.7.1.B for discussion of coverage of PENS for diagnostic purposes.)

The two new Noridian coverage articles clarify that Peripheral Nerve Field Stimulation (PNFS), also known as Peripheral Subcutaneous Field Stimulation (PSFS) is not covered for any condition. PNFS refers to use of a lead placed to stimulate the subcutaneous distal distribution of an area of pain (indirectly stimulating the peripheral nerve). This service should also be billed with the unlisted CPT code 64999 for both the trial and permanent insertion of the electrode array.

One last peripheral nerve stimulation service for which Novitas JH and JL has a non-coverage policy is Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device).  As with the other non-covered peripheral nerve stimulation procedures, Novitas reports that auricular peripheral nerve stimulation has been inappropriately billed to Medicare using an incorrect CPT code (CPT 64555).  Per the Novitas policy, “The CPT code 64555, does not describe the procedure of auricular acupuncture stimulation and it should be coded using the NOC CPT code 64999 - unlisted procedure, nervous system….The term for the device used for this procedure (e.g. NeuroStim/NSS, P-Stim, ANSiStim, E-Pulse, Electro-Acupuncture, NSS-2 Bridge) should be reported in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B.

The service for auricular peripheral nerve simulation (CPT code 64999) will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Act.

While the information given in this article is directed to Neurostim system/NSS, P-Stim, ANSiStim, E-Pulse, and NSS-2 Bridge, other current or future devices when used for the procedure auricular peripheral nerve stimulation or electro-acupuncture, would also be considered a non-covered service.” The WPS policy that addresses PENS and PNT also states that any ear or auricular electrical devices (e.g., DyAnsys®) are also non-covered by Medicare as electrical acupuncture.

With all the different types of peripheral nerve stimulation and the different coverage requirements, make sure your facility is assigning the correct code and that documentation supports the coverage indications. Denied claims can get on your last nerve.