Am I able to bill for dosing adjustments?
The dosing codes applicable to VNS Therapy are as follows:
95970 Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements); simple or complex neurostimulator, without reprogramming.
95974 Complex cranial nerve neurostimulator pulse generator/ transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour.
95975 Complex cranial nerve neurostimulator pulse generator/ transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (list separately in addition to code for primary procedure).
Initial and or follow-up dose adjustments are a service billable to payers. You may need to request that the payer add the analysis/programming CPT Codes to your physician profile in order for the service to be reimbursed. Your Payer Representative or Provider Services within the payer organization would be a good starting point. Please contact your Cyberonics Regional Access Manager for further assistance with this.
Are Evaluation and Management codes appropriate to use with these procedure codes?
In the office, Evaluation and Management codes can be used with procedure codes if significant enough to require additional work to perform the key components of a problem-oriented E/M service. An insignificant or trivial problem/abnormality that is encountered in the process of performing the procedure and that does not require additional work, and the performance of the key components of a problem-oriented E/M service, should not be reported (CPT 2003). Appropriate history, physician examination, and medical decision making always need to be shown when adding an E/M code.
What is important in the medical record documentation?
If an inpatient procedure is being done, the medical record documentation must support the need for the inpatient admission. In the outpatient setting, good principles of medical record documentation must also be followed. It is always appropriate to include chief complaint and/or reason for the encounter and co-morbidities and, as appropriate, relevant history, examination findings, and prior diagnostic test results. The date and legible identification of the health care professional should always be documented and the entire medical record should be complete and legible.
The ICD-9-CM and CPT codes reported on a claim form or billing statement should be supported by the documentation in the medical record and be at a level sufficient for a clinical peer to determine whether the services have been accurately coded.
Is there a difference between pre-certification and prior authorization?
Yes. Pre-certification refers to obtaining authorization for the hospital stay (number of days) and typically refers to hospital reimbursement only. Prior authorization is the verification of benefits and determination of coverage for the procedure to be performed. This refers to both physician and hospital reimbursement.
What is the average length of time it takes to obtain a decision in the prior authorization process?
The average expected length of time for a decision varies widely from plan to plan and depends on whether a formal review is required, if alternative treatments are required, and/or if a second opinion is required prior to a decision.
How should a physician establish fees for procedures involving VNS Therapy?
- Compare the relative value units and charges for other procedures the physician is currently performing.
- Reference the usual and customary rates for the physicians' geographical area.
- Refer to the Physicians Fee Schedule Reference Manual.
What supporting material do you suggest using when payers request information about VNS Therapy?
- Summary of relevant clinical articles.
- Implant procedure overview.
- Commonly billed codes.
If an insurer denies this procedure, what alternative do you have?
- Request information regarding appeal process.
- Repeat prior authorization process for "payable benefits subject to review," submitting required materials, etc.
- Appeal is available as long as an appealable issue exists. The physician and patient must decide if the decision will be appealed. An appeal letter may be submitted if the payer is provided with new information to review. Absence of benefits under the policy is not an appealable issue.
- Your Cyberonics Regional Access Manager can work with you to help provide education to the payer. Some of our educational programs have CEUs available for nurses and case managers.
- The Cyberonics Regional Case Manager is able to assist you in your appeal process. Please contact us by phone at (877) 669-4867 or by fax at (877) 577-7205.
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