Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12x Hospital Inpatient (Medicare Part B only)
13x Hospital Outpatient
83x Ambulatory Surgery Center
85x Critical Access Hospital
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Claims Processing Manual, for further guidance.
0360 Operating Room Services – General Classification
0361 Operating Room Services – Minor Surgery
0362 Operating Room Services – Organ Transplant – Other than Kidney
0367 Operating Room Services – Kidney Transplant
0369 Operating Room Services – Other OR Services
CPT/HCPCS Codes
Group 1 Paragraph
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
NOTE: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.
Group 1 Codes
64561 Implant neuroelectrodes
64581 Implant neuroelectrodes
64585 Revise/remove neuroelectrode
A4290 Sacral nerve stim test lead
ICD-9 Codes that Support Medical Necessity
Group 1 Paragraph : It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Note: CPT/HCPCS Code 64585 is used for various other services. Medicare is not establishing limited coverage for this code at this time.
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 64561, 64581 and A4290:
Group 1 Codes
596.52 LOW BLADDER COMPLIANCE
596.55 DETRUSOR SPHINCTER DYSSYNERGIA
787.60 FULL INCONTINENCE OF FECES
788.20 RETENTION OF URINE UNSPECIFIED
788.21 INCOMPLETE BLADDER EMPTYING
788.29 OTHER SPECIFIED RETENTION OF URINE
788.30 URINARY INCONTINENCE UNSPECIFIED
788.31 URGE INCONTINENCE
788.32 STRESS INCONTINENCE MALE
788.33 MIXED INCONTINENCE (MALE) (FEMALE)
788.41 URINARY FREQUENCY
788.64 URINARY HESITANCY
788.91 FUNCTIONAL URINARY INCONTINENCE
788.99 OTHER SYMPTOMS INVOLVING URINARY SYSTEM
ICD-9 Codes that DO NOT Support Medical Necessity
Associated Information
Documentation Requirements
1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3. The submitted medical record must support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
4. The medical record documentation must support the medical necessity of the services as directed in this policy.
5. Documentation must include objective evidence supporting a covered indication and objective evidence that the nationally prescribed indications and limitations are met. Such documentation should include the conservative measure used, the length of time it was tried, and any other information to support coverage.
