Axonics 2024 Sacral Neuromodulation Therapy User Guide

Axonics 2024 Sacral Neuromodulation Therapy

Product Specifications

• Product Name: Axonics Sacral Neuromodulation
• Model: 2024
• Therapies: Sacral neuromodulation and urethral bulking

Product Usage Instructions

Implant, Removal, and Revision Guidance

Electrode Array Implant (64561)

Facility Reimbursement:

• Hospital Outpatient:
  • Medicare CAPC National Avg SI Payment: $6,523
• Ambulatory Surgery Center:
  • Medicare National Avg Payment: $5,041

Revision or Removal:

• 64585 – Revision or removal of peripheral neurostimulator electrode array: $3,245
• 64595 – Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver: $3,245

Outpatient Hospital Payment Example:

• Basic Trial (Unilateral): $6,523
• Basic Trial (Bilateral): $6,523
• Full Implant (System): $20,865
• Advanced Trial (Stage 1): $6,523
• INS Implant (Stage 2): $20,865

Frequently Asked Questions (FAQ)

• Q: How can I obtain more information on coding and reimbursement for Axonics Sacral Neuromodulation?
  A: You can contact our reimbursement team via email at reimbursement@axonics.com or call 1 877-228-7760 for more information.

• Q: Is it necessary to consult with payers or legal counsel regarding coding and payment matters?
  A: Yes, Axonics recommends consulting with payers, reimbursement specialists, and legal counsel for accurate guidance on coding, coverage, and payment.

Disclaimer
Axonics, Inc. (“Axonics”) has compiled the information in this Guide from third party sources for your convenience. This information does not constitute reimbursement or legal advice. Axonics does not guarantee that Medicare or any public or private payer will cover any products or services at any particular level or that the codes identified in this Guide will be accepted for Axonics therapy. Axonics specifically disclaims and excludes any representation or warranty relating to reimbursement. Laws, regulations, and payer policies concerning reimbursement are complex and change frequently, and healthcare providers are responsible for all decisions relating to coding and reimbursement submissions. Please note that the information in this Guide is subject to change without notice. It is always the health care provider’s responsibility to determine medical necessity and submit appropriate codes, modifiers, and charges for services rendered. Axonics assumes no liability for information contained or not contained herein.
Axonics recommends that you consult with your payers, reimbursement specialist and/or legal counsel regarding coding, coverage, and payment matters.
CPT Copyright 2021 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Payments may be subject to reduced payment when multiple procedures are performed on the same day.

REIMBURSEMENT RESOURCES

We offer several resources to provide information related to coding, coverage, and payment for sacral neuromodulation and urethral bulking therapies.

IMPLANT, REMOVAL / REVISION GUIDANCE

Electrode Array Implant (64561)

• Report CPT 64561 for either a temporary or permanent lead placed percutaneoulsly. (CPT updated Guidance in 2019)
• Report CPT 64561 based on the surgical approach (percutaneous)
• The selection of the CPT code is not based on the type of lead placed (temporary or permanent)

Facility Reimbursement

Outpatient Hospital Payment Example

*Total payment for all services reported is based on the primary procedure in the C-APC.

Ambulatory Surgery Center (ASC) Payment Example

ASC Payment Indicators:

• J8 Device-intensive procedure; paid at adjusted rate
• A2 Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
• Z3 Radiology or diagnostic service paid separately when provided integral to a surgical procedure on ASC list; payment based on MPFS non-facility PE RVUs

OPPS Status Indicators:
Status Indicator : J1 Hospital Part B Services Paid Through a Comprehensive APC (C-APC)

NOTE : Assignment of a CPT® procedure code to a C-APCs is considered a primary procedure. All other services and procedures reported on the claim would be considered adjunctive to the primary procedure. CMS will make a single APC payment for the entire hospital outpatient encounter. There is no additional payment for the adjunctive services or procedures. When procedures performed in an episode of care map to multiple C-APCs, the entire episode will map to the highest paying C-APC.

• Status Indicator : S Significant Procedure Not Subject to Multiple Procedure Discounting

Physician Reimbursement

CPT ®

Code

| **Description| ****Global| ****Work| Non-Facility (Office)| ****Facility| Non-Facility (Office)| ****Facility**
---|---|---|---|---|---|---|---
Electrode and Pulse Generator Implant|

64561

| Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including imaging guidance, if performed| ****

10

| ****

5.44

| ****

22.01

| ****

9.06

| ****

$720

| ****

$297

64590| Insertion or replacement of peripheral or gastric neurostimulator or receiver, direct to inductive coupling| 10| 5.1| 13.27| 8.83| $435| $289
Revision or Removal| | | | | |
64585| Revision or removal of peripheral neurostimulator electrode array| 10| 2.11| 7.28| 4.33| $238| $142
64595| Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver| 10| 3.79| 10.94| 6.89| ****

$358

| ****

$226

Physician Payment Example – Facility Setting

Procedure| CPT ® Code| Short Descriptor| Physician Modifier| Physician Payment (Facility)
---|---|---|---|---
Basic Trial (Unilateral)| 64561| Implant microelectrodes (percutaneous)| NA| $297
Basic Trial (Bilateral)| 64561| Implant neuroelectrodes (percutaneous)| -50| $446

Full Implant (System)

| 64561| Implant neuroelectrodes (percutaneous)| NA| $297
64590| Inst/Redo PN/Gastr stimulator| -51| $146
95972| Complex Programming| NA| $39
Advanced Trial (Stage 1)| 64561| Implant neuroelecrodes (percutaneous)| NA| $297

INS Implant (Stage 2)

| 64590| Inst/Redo PN/Gastr stimulator| -58| $289
95972| Complex Programming| NA| $39
Programming| 95971| Simple Programming| NA| $38
95972| Complex Programming| NA| $39

Physician Payment Example – Non- Facility (Office)

Procedure| CPT ® Code| Short Descriptor| Physician Modifier| Physician Payment
---|---|---|---|---
Basic Trial (Unilateral)| 64561| Implant neuroelectrodes (percutaneous)| NA| $720
Basic Trial (Bilateral)| 64561| Implant neuroelectrodes (percutaneous)| -50| $1,080

PROGRAMMING

Reporting Guidance (95970-95972)
Programming

• Simple programming includes adjustment of one to three parameter(s)
• Complex programming includes adjustment of more than three parameters
• Single parameter that is adjusted two or more times during a programming session counts as one parameter
• Electronic analysis of a device (95970) is not reported separately at the time of implantation

**PI**
Programming

95970

| Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming|

5734

| ****

$122

| ****

S

| ****

NA

| ****

NA

95971

| ****

Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional

| ****

5742

| ****

$92

| ****

S

| ****

NA

| ****

NA

95972

| Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional|

5742

| ****

$92

| ****

S

| ****

NA

| ****

NA

Physician Reimbursement

CPT ®

Code

| **Description| ****Global Work| Non-Facility (Office)| ****Facility| Non-Facility (Office)| ****Facility**
Programming|

95970

| **** Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician

or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming

| ****

xx

| ****

0.35

| ****

0.56

| ****

0.54

| ****

$18

| ****

$18

95971

| Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional|

xx

| ****

0.78

| ****

1.44

| ****

1.15

| ****

$47

| ****

$38

95972| Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional| ****

xx

| ****

0.8

| ****

1.70

| ****

1.19

| ****

$56

| ****

$3

CPT® MODIFIERS

-58

| Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
-59| Distinct Procedural Service
-73| Discontinued Outpatient Procedure Prior to Anesthesia Administration (Facility Reporting Only)
-74| Discontinued Outpatient Procedure After Anesthesia Administration (Facility Reporting Only)

POSSIBLE ICD-10-CM DIAGNOSES

ICD-10-CM diagnosis codes are used by providers to report patient conditions. List all diagnoses on the claim form and code to the highest available level of specificity based on the documentation in the patient’s medical record. The following ICD-10-CM codes describe conditions commonly treated with the Axonics System. Other codes may apply based on the patient condition. For a complete list of codes and descriptions, consult the current ICD- 10-CM manual.

ICD-10-CM Codes

Z45.42

| Encounter for adjustment and management of neuropacemaker (brain) (peripheral nerve) (spinal cord)

HCPCS LEVEL II CODING GUIDANCE

HCPCS Level II Codes are alphanumeric codes that describe products, supplies, and services not included as part of the CPT® Code system. HCPCS contains a category of “C” codes that are billed on Medicare claims for the Hospital Outpatient Prospective Payment System (HOPPS) for specific device-dependent procedures. Hospital chargemasters are list these codes for identification/costs.
Private payers may use C codes or Durable Medical Equipment Prosthetic and Orthotic (DMEPOS) HCPCS codes to identify devices.

Medicare Device C Codes for Hospital Outpatient Reporting

battery and charging system
C1767| Generator, neurostimulator (implantable), non-rechargeable
C1787| Patient Programmer, neurostimulator
C1894| Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser
C1883| Adaptor/extension, pacing lead or neurostimulator or lead (implantable)

DMEPOS Codes

rechargeable, includes extension
L8681| Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
L8689| External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

Check with private payers if the “L” or “C” HCPCS codes are applicable.

Sou rces:

• Calendar Year 2024 Medicare Outpatient Prospective Payment System, Final Rule [CMS-1786-FC], Federal Register, November 2nd, 2023 and its associated addenda posted on the Centers for Medicare and Medicaid Services (CMS) web site on November 2nd, 2023.
• Updated Conversion Factor $32.7442. 2024 National Physician Fee Schedule Relative Value File January Release, November 2, 2023.
• Medicare payment allowable rates shown above do not reflect the automatic payment cuts required under the sequestration process of the 2011 Budget Control Act. Calendar Year 2024 Medicare Physician
• Fee Schedule, Final Rule [CMS-1784-F], Federal Register, November 2, 2023, posted on the CMS website November 2nd, 2023.. No geographic adjustments have been made to the reported payment rates.
  • 2024 ICD-10-CM Professional The complete office code set, Optum 360 2024
  • 2024 AMA CPT 2024 Professional Edition
  • 2024 HCPCS Level II Professional Edition AMA
  • CPT Assistant October 2021 Volume 31 Issue 10 page 7

Axonics Reimbursement Support Center Email: reimbursement@axonics.com Phone: 1 877-228-7760 (Messages only) Fax: 1 949-333-1573 Please allow 24 hours for a response.

© 2022-2024 Axonics, Inc. All Rights Reserved 105-0078-005rB 12/21
Axonics Sacral Neuromodulation

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