A Little More Paperwork: Medicare Refines Neurostimulator Policy

Summary: Medicare places a new reimbursement hurdle for providers who perform spinal neurostimulator services. However, payment is not restricted where the pain practitioner's paperwork passes muster.

In the Cold War spy thriller, Firefox, Clint Eastwood's character is in the Soviet Union on a clandestine mission for the American government. He is approached by a representative of the feared KGB, who demands: "Your papers, please." Nervously, the American hands his passport and other identifying documents over. After a few seconds, he hears to his horror the dreaded words from the KGB enforcer: "Your papers are not in order."

Many in the medical provider community can occasionally relate to the angst portrayed in the above scene. You've provided expert care to a patient in need; you've documented the service in the manner you deemed appropriate; but then you get a notification from the payer that your documentation didn't meet their criteria. Your papers were not in order! As a result, the word "denied" now appears prominently on the EOB. You just can't get around it: insurance companies will often force you to dot every "i" and cross every "t" from a medical record perspective in order to get paid. It turns out that Medicare is now requiring greater attention to paperwork when it comes to a certain pain-related service.

A New Hurdle

In last week's article, we addressed chronic pain components within an anesthesia practice. As a follow-up, this may be a good time to alert those anesthesia groups who either have, or are thinking about installing, a chronic pain element to their range of services that there is a relatively new requirement that Medicare has imposed regarding a key chronic pain procedure.

In October of last year, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) presented a finding that the government had overpaid on implanted neurostimulator claims by $636 million. As a result, the Centers for Medicare and Medicaid Services (CMS) issued a ruling that providers wishing to bill for implanted spinal neurostimulator services "in the hospital outpatient department" would first need to obtain authorization from their individual Medicare administrative contractor (MAC).

The new ruling was published in a Medicare Learning Network (MLN) article earlier this month. Inexplicably, the MLN article says the ruling applies to services going back to July 1 of last year. According to a document linked within the MLN article, the spinal neurostimulator implantation codes (CPT 63685 - insertion or replacement of spinal neurostimulator pulse generator or receiver, and CPT 63688 - revision or removal of implanted spinal neurostimulator pulse generator or receiver) had been temporarily removed from the pre-authorization list last year. Apparently, the March 2022 MLN is CMS's way of advising that these services are now back on the list. It should be noted that the March MLN advisory does not specify which neurostimulators codes are in view, stating only that the pre-authorization requirement applied to "implanted spinal neurostimulators."

Accordingly, we recommend that those providers performing any implanted spinal neurostimulator service in the outpatient hospital setting contact their Medicare carrier prior to the service to determine if a pre-authorization is needed and, if so, to obtain such when these services are being planned for a Medicare patient.

Justifying Payment

Significantly, the rationale the OIG gave for their determination of massive overpayment for neurostimulator claims was due to a lack of sufficient provider documentation that supported the medical necessity of the procedure. With this in mind, it may be helpful at this point to provide a bit of background on the medical necessity and documentation requirements related to these services.

Implanted spinal neurostimulator services, such as those reflected by codes 63685 and 63688 (cited above), will need to be supported from a medical necessity perspective in the provider's medical record. To help illustrate what this involves, we will provide a couple of excerpts from the policy pages of representative MACs. For example, a 2019 Novitas Medicare article (formerly local coverage determination, or LCD) states the following concerning the necessity of documenting appropriate primary and secondary diagnoses:

Dual diagnosis requirement: Claims submitted for spinal cord stimulation must include both a primary ICD10-CM diagnosis code indicating the reason for the procedure and a secondary ICD-10-CM diagnosis code indicating the etiology of the chronic pain. The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes 63650, 63655 and 63685: Primary Diagnosis Codes G89.21 Chronic pain due to trauma; G89.28 Other chronic postprocedural pain; G89.3 Neoplasm related pain (acute) (chronic); G89.4 Chronic pain syndrome.

The policy goes on to provide a list of dozens of secondary diagnoses from which the provider should additionally choose, where applicable.

A 2021 Palmetto Medicare LCD on "Spinal Cord Stimulators for Chronic Pain" includes the following documentation requirements:

Patients must have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include psychological, as well as physical, evaluation). Documentation of the history and careful screening must be available in the patient chart if requested.

So, does your documentation contain evidence of evaluations by a multidisciplinary team or a psychological screening? These are the kinds of omissions in the medical record that the OIG report used as grounds for concluding that provider documentation was often insufficient relative to neurostimulator claims.

In conclusion, we must stress two takeaways from today's article. First, for Medicare patients undergoing implanted spinal stimulator procedures in the outpatient hospital setting, please check ahead of time with your MAC to ensure the procedure is preauthorized. Second, as there are several MACs throughout the country, be sure to consult the LCD, medical policy or article database on your particular Medicare carrier's website to ensure you have thoroughly reviewed the documentation and other requirements for submitting neurostimulator services to Medicare. Each carrier's neurostimulator policy may be a little different. It will be important to know what your MAC requires.

If you have any questions about today's topic, please contact your account executive or you can reach out to us at info@anesthesiallc.com.