# P-STIM - Has anyone billed



## gr8gal61

Has anyone billed for the implant of the P-stim - behind the ear? One supplier has given us codes then our new vendor is saying they are right!!!!!!!!!!!!! I need help if anyone has successfully billed for this fairly new product. There is a 3 step protocol to follow - patient receives the implant and the 5th through the 10th day comes back in for another (which is still considered global during this time) then about 7 to 10 days later the final of the series is performed. I have been given 64555 + L8680 x 3 on the 1st session / 64555-58 along with the L8680 x 3 on the second utilization of the 58 modifier during the global period) then on the final bill it the same as the first, 64555 & L8680 x 3 

Our old vendor instructed us to use the above codes PLUS an OV and 95970 analyze neurostim no program however the doctors do absolutely nothing to the stimulator besides the implant. Payment has been received on all but the 95970. 

HELP


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## dwaldman

You would not want to report 95970 if performed by the manufacturer's representative or there is not documentation to support the physician  performed analysis of the device. I don't personally know the coding for this procedure.


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## marvelh

Be wary of medical device rep's recommendations for codes.  They are in sales and sometimes need to provide potentially incorrect information to close the deal.  It is much more difficult to make the sale if providing information that an unlisted code should be billed!

The P-Stim device is NOT a percutaneous placed peripheral nerve neurostimulator.  It is NOT compliant to report 64555, L8680 and/or 95870 for the placement of this device.

Here is a link to the website so you can see a picture and description of the device:
http://www.biegler.com/pstim.en.html

It is instead a form of auriculotherapy.  Per a non-published AMA CPT response, code 64999 should be reported.  There is a new HCPCS code that maybe considered -
S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the patient


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## capricew

gr8gal61 said:


> Has anyone billed for the implant of the P-stim - behind the ear? One supplier has given us codes then our new vendor is saying they are right!!!!!!!!!!!!! I need help if anyone has successfully billed for this fairly new product. There is a 3 step protocol to follow - patient receives the implant and the 5th through the 10th day comes back in for another (which is still considered global during this time) then about 7 to 10 days later the final of the series is performed. I have been given 64555 + L8680 x 3 on the 1st session / 64555-58 along with the L8680 x 3 on the second utilization of the 58 modifier during the global period) then on the final bill it the same as the first, 64555 & L8680 x 3
> 
> Our old vendor instructed us to use the above codes PLUS an OV and 95970 analyze neurostim no program however the doctors do absolutely nothing to the stimulator besides the implant. Payment has been received on all but the 95970.
> 
> HELP



I would be cautious with the payer you are dealing with.  With Medicare, it would be billed as unlisted.  But, to my findings, most commercial payers specifically have a policy for this procedure and the majority of them (BCBS, Cigna, Aetna etc) deem it investigational.  

Secondly, know what your payers definition of an implant is.  For example, Medicare defines an implant as a device that replaces a body organ or cavity and/or is _implanted into the body and left there for 30 days or more._  The above procedure is not implanting anything, it is more of an acupuncture type procedure where the device is slightly put into the skin and the electrodes remain within the skin like an acupuncture needle.  Now that you know this, do you really think this is an implant?  Not hardly.  

The fact that the majority of your claim was paid does not mean you billed it correctly.  For example, Medicare will pay the codes you billed because they are valid codes and they are assuming those are the procedures you performed.  But, if Medicare were to come audit you and see the notes associated with what you billed I am confident you would end up giving the money back.  

I have to agree with Marvel, be very careful when billing this.  For Medicare, bill unlisted and send special reports and documentation with your billing.  For commercial, look at their specific medical policies for this procedure- you will be surprised how many payers come right out and state it is not a covered procedure.

Good luck!


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## KMCFADYEN

I would be interested in hearing from anyone that has billed this correctly and recieved reimbursment from medicare and any of the blues.  I have a Dr that has been sold on this by the reps.  I am skeptical as I have watched the video of this procedure.  I have spoken to the reps and to their "coding specialist".  I really do not want to have to bill this but I cannot keep the Dr from doing it.


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## dwaldman

Bill it as the non-published response says: 64999 and the other coding guidance provided by forum member Marvelh. If they deny it, appeal in writing. And then do a second level appeal if necessary. If they state in writing they don't cover it then that will be the process of determining the coverage for this new procedure with questionable suggested coding by the companies reps and unknown coverage by Medicare.


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## DCOMPauditor

I am having the exact same problem.  How can I justify to my provider that billing an unlisted code is the correct way to appropriately code a PSTIM.  He is adamant that a PSTIM is a percutaneous implant because it is as he says "through the skin".  How can I explain to him that this is not percutaneous?  Any help is really appreciated...  How can I get that AMA response?


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## dwaldman

http://www.ama-assn.org/ama/pub/phy...coding-billing-insurance/cpt/cpt-network.page

If you don't want to currently pay for a $250.00 subscription to the AMA CPT Network and then pay for credits for questions. You can purchase one question for $80.00,  if I was you I would personally pay for it on a credit card and submit the question to the AMA when you get the response and confirm the correct coding it will be worth the money to show the provider you are willing to personally pay for a response from the AMA to support correct coding. I have done this in the past because I am not going to debate if the company is or isn't going to pay for question about coding. Some of the response I have receive that I have personally paid for show the physicians there is direct way to obtain a formal response from the AMA and it is not the coders opinion versus the physician it is straight from the source. If you request the reimbursement up front it is possible they will just say it isn't necessary to send it but if you go ahead and pay for it yourself, you can have the response you read and feel you took the necessary measures. 

The full response the other forum member received will not be able to be shared. So you will have to send it yourself to get a similiar response from the AMA


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## dwaldman

jaimy,

To make it easier I had some extra credits so I went ahead and sent the question to the AMA CPT Network. Let me know your email and I will let you know when they complete it.


Last Updated: 10/17/2013 09:38 PM 


Section: Surgery 


Sub-Section: Nervous System 


Requestor Name: David Waldman 


Question Type: General CPT Coding Question 


Question:
 Can CPT 64555 Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) be reported for the P-STIM procedure? Below is a brief description of the procedure: "The P-STIM is the only patented ambulatory continuous electrical auricular nerve stimulation treatment that is FDA cleared for use on chronic and acute pain."  


Response:


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## DCOMPauditor

That would be great.  My e-mail is jpinheiro@natpain.com or jaimypinheiro1982@hotmail.com

Thanks Dwaldman for the help!


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## aschweikowsky

would you be able to share the response with me as well?  aschweikowsky@yahoo.com.

If not - I understand and I will try to get the boss to pay for it.

Thank you!


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## dwaldman

Here is part of the response.

From a CPT coding perspective, based solely upon the information provided in your inquiry, please note CPT code 64999, Unlisted procedure, nervous system, may be used to report the P-STIM procedure. From a CPT coding perspective, based solely upon the information provided in your inquiry, please note CPT code 64999, Unlisted procedure, nervous system, may be used to report the P-STIM procedure. When reporting an unlisted procedure, a report should be submitted with the claim. Pertinent information should include an adequate description of the nature and extent, and need for the procedure and time, effort, and equipment necessary to provide the service. Further, it would not be appropriate to report code 64555, Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve), as this code is for implanted (directly into the body) nerve stimulator.


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## rwhite@mscitx.com

dwaldman said:


> jaimy,
> 
> To make it easier I had some extra credits so I went ahead and sent the question to the AMA CPT Network. Let me know your email and I will let you know when they complete it.
> 
> 
> Last Updated: 10/17/2013 09:38 PM
> 
> 
> Section: Surgery
> 
> 
> Sub-Section: Nervous System
> 
> 
> Requestor Name: David Waldman
> 
> 
> Question Type: General CPT Coding Question
> 
> 
> Question:
> Can CPT 64555 Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) be reported for the P-STIM procedure? Below is a brief description of the procedure: "The P-STIM is the only patented ambulatory continuous electrical auricular nerve stimulation treatment that is FDA cleared for use on chronic and acute pain."
> 
> 
> Response:


That would be great.  My physician is also stating the correct way to bill the PSTim is L8680,64555 and 95970...My email is gwhite@mscitx.com. thanks


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## Cassandra Stone

Dwaldman, any chance you could send the response to me as well? stonecm@hotmail.com. I've had several discussions with our providers regarding this procedure and am still asked to code using 64550, 95970 and 64550.


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## gr8gal61

dwaldman said:


> Here is part of the response.
> 
> From a CPT coding perspective, based solely upon the information provided in your inquiry, please note CPT code 64999, Unlisted procedure, nervous system, may be used to report the P-STIM procedure. From a CPT coding perspective, based solely upon the information provided in your inquiry, please note CPT code 64999, Unlisted procedure, nervous system, may be used to report the P-STIM procedure. When reporting an unlisted procedure, a report should be submitted with the claim. Pertinent information should include an adequate description of the nature and extent, and need for the procedure and time, effort, and equipment necessary to provide the service. Further, it would not be appropriate to report code 64555, Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve), as this code is for implanted (directly into the body) nerve stimulator.



Thank you for the response. Would you kindly send the remai respo to my email also or post here? Thank you very kindly for your help. Gr8gal61@yahoo.com


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## smokey

marvelh said:


> Be wary of medical device rep's recommendations for codes.  They are in sales and sometimes need to provide potentially incorrect information to close the deal.  It is much more difficult to make the sale if providing information that an unlisted code should be billed!
> 
> The P-Stim device is NOT a percutaneous placed peripheral nerve neurostimulator.  It is NOT compliant to report 64555, L8680 and/or 95870 for the placement of this device.
> 
> Here is a link to the website so you can see a picture and description of the device:
> http://www.biegler.com/pstim.en.html
> 
> It is instead a form of auriculotherapy.  Per a non-published AMA CPT response, code 64999 should be reported.  There is a new HCPCS code that maybe considered -
> S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the patient


Can anyone please send me something in writing from AMA or CMS or even the main payors about PSTIM and that it should be billed as unlisted?  I dont' want my doctor to go down the wrong road............Thank you.
dl_pittman@msn.com


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## opmramirez71@gmail.com

wondering what was the outcome? I know this year they are not covering L8680 and my providers here are doing Pstims along with L8680 reporting 64555 :/


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## dwaldman

opmramirez71@gmail.com,

Per the AMA CPT Assistant within their published Q & A, the procedure is unlisted.

February 2014 page 11

Frequently Asked Questions:Surgery: Nervous System

Question: May CPT code 64999, Unlisted procedure, nervous system, be used to report implantation of the P-STIM device for pain management? 

Answer: Yes. CPT code 64999, Unlisted procedure, nervous system, would be used to report P-STIM procedures and services. Reporting for unlisted procedures and services must be documented to include information such as the nature, extent, and need for the procedure, as well as the time, effort, and equipment necessary to provide the procedure or service.


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## gamecocknana

*P stim helppppppppppp*

We bill 64555 for the PStim and were billing L8699 for the electrodes.  Medicare has informed me they will not pay the L8699 code but that there is another HCPCS code to use for the electrodes BUT they would not give me the code.  All Medicare would tell me is it is an L HCPC's code. I asked Medicare about the 64999 code and was told that code would not pay in SC not to use it.   

DOES ANYONE KNOW WHICH CODE THIS WOULD BE?  I have it narrowed down to 4 L8679, L8681, L8682 or L8683 but none mention electrodes.  Very frustrated over this and need help badly!


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## dwaldman

As seen in the article, below they reference the PSTIM procedure as  designated as an unlisted procedure by the AMA. A customer service representative telling you not to bill unlisted that they will deny was not a formal response from your Medicare carrier that it is appropriate to use CPT 64555. I would talk to the vendor regarding the L code that represent the device that you are purchasing. The L codes you provided do not appear they are designed to represent this technology.

http://www.beckersasc.com/asc-codin...a-bentin-of-coding-compliance-management.html

PSTIM Reporting: What Does Your Carrier Advise? Q&A With Cristina Bentin of Coding Compliance Management

 Written by Rachel Fields |   May 07, 2012   

CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

This article features a Q&A with Cristina Bentin, CCS-P, CPC-H, CMA, president of Coding Compliance Management. Learn more about Coding Compliance Management here.  

Q: Our ASC has been receiving conflicting information from some vendors regarding the appropriate reporting of the PSTIM procedure. In regards to commercial carriers, should we report CPT code 64555, S8930, 64999, or a code(s) from the acupuncture series of codes?

Cristina Bentin: There has been considerable confusion regarding the reporting of the PSTIM? procedure, an innovative procedure utilized to reduce or alleviate acute and chronic pain based on the principle of auricular nerve stimulation. Available information and recommendations regarding code selections have ranged from reporting CPT code 64555, reporting the unlisted code 64999, reporting from the 99XXX codes for acupuncture, or reporting HCPCS code S8930. It is important your ASC does its research.

While reporting opinions and recommendations are typically based on documentation and research information available at the time, procedure reporting can and will change as directives and guidelines change and/or become available. From a coding perspective, what may be an accurate code for one procedure may not apply to a similar procedure. In addition, code selections one day may not be correct code selections the next month. It is highly recommended that facilities and providers verify individual carrier reporting guidelines for the PSTIM? procedure prior to performing these procedures. Facilities should not assume reimbursement information presented in the past is correct and/or still applicable at this time.

With regards to the PSTIM? procedure, key verbiage within the procedural notes for the PSTIM? has understandably misled some coders, consultants, and vendors to an incorrect code selection since similar terminology is also utilized in procedural notes traditionally and legitimately warranting CPT code selection 64555, Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve), thus the variances in past and current recommendations and/or reporting.

A facility may "lean" towards the reporting of CPT 64555 since this code "appears" to imply exactly that of the PSTIM? procedure. As of this writing, according to the American Medical Association, CPT 64555 is not appropriate for the PSTIM? procedure. According to an AMA inquiry, CPT code 64999, unlisted procedure nervous system should be reported. Facilities should understand that even these coding directives are subject to change. In addition, commercial carrier directives may differ from the AMA's recommendation and/or CMS directives/guidelines. CMS should be queried with specific questions regarding the PSTIM? procedure and its reporting policies to include medical necessity and provider requirements when applicable.

The PSTIM? procedure has been compared by some commercial carriers to acupuncture procedures with carrier directives ranging from the unlisted CPT code 64999 to the potential reporting of codes from the acupuncture code series. Still, other carriers consider the procedure investigational and recommend the reporting of unlisted code 64999.  

Physicians not in agreement with the current AMA directive are encouraged to contact the AMA directly for a peer to peer review. The AMA may also be contacted to initiate support for the development of a code to accurately describe this procedure.

While it is common for vendors to provide facilities with reimbursement information to assist in their decision-making process, ultimately, it is the facility?s responsibility to verify and ensure correct reporting of its surgical procedures based on its carrier specific directives.


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## gamecocknana

*Pstim*

Thanks for your response.  After I posted this question I called Medicare and fortunately spoke to someone who helped me out.  SC can not bill the 64999 so we bill the 64555 as J MAC B 11 pays this code in this state. 64999 I am told is getting paid in Florida but that is the only state mentioned in relation to that 64999 code.  The electrode reimbursement was the main issue.  We had been advised by the company that makes this product and the sales rep to use L8699 with a specific description listed for that code.  Unfortunately that was incorrect and this code was being denied.  This is where the issue came from.  When I originally spoke to Medicare they advised me, but would not tell me, there is another HCPCS code that exist that would be covered and I would have to locate that code as they were not allowed to give me the code.  

I research every aspect of the 2015 HCPC's book and narrowed it down to a few codes and called back.  This time I was informed one of the codes I picked would be the correct code and to bill using that code with a specific description with the product invoice and procedure notes.  E1399 with description - PStim electrode-acupuncture device supply was the code I was advised to use for the electrodes for the PSTIM.  I have already filed some claims as a test to see what happens.  I cannot say for a certainty that this code will pay but per Medicare's suggestion I have done so.  

Thanks again for your response.


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