Neurology & Pain Management Coding Alert

CMS stops TENS pay for most low back pain cases, but other payers might allow.

Just because CMS announced in June that it will no longer cover transcutaneous electrical nerve stimulation (TENS) for chronic low back pain doesn't mean you should give up all hope. Other payers might reimburse providers for the use of TENs for chronic low back pain, however, so keep these tips in mind when faced with those claims.

Get Clear on What Constitutes Chronic Low Back Pain

Medicare has defined chronic low back pain (CLBP) as:

• An episode of low back pain that has persisted for three months or longer; and
• Is not a manifestation of a clearly defined and generally recognizable primary disease entity

In the June 8, 2012 memo, Medicare explained what distinguishes "primary disease manifestation." According to the memo, "For example, there are cancers that, through metastatic spread to the spine or pelvis, may elicit pain in the lower back as a symptom; and certain systemic diseases such as rheumatoid arthritis and multiple sclerosis manifest many debilitating symptoms of which low back pain is not the primary focus."

Know What's Reasonable and Necessary

"Many of my patients, particularly the elderly, want a fast-acting solution for their pain that provides minimal sedation and does not affect their mental clarity or bowel function," says Jeremy Scarlett, MD, a pain management specialist with Advanced Pain Management in Milwaukee, Wis. "The TENS unit is an excellent option for these patients."

However, know that payers might have differing guidelines for what constitutes "reasonable and necessary" treatment with TENS. Criteria could include:

• When the physician uses a TENS unit to treat acute postoperative pain, medical necessity is usually limited to a relatively short period of time, such as 30 days or less from the day of surgery.
• All four Medicare DME contractors' LCDs (local coverage determinations) require that the patient record document the location of pain, duration of the patient's pain, and the presumed etiology of the pain when TENS is used to treat chronic (non-low back) pain. Notes regarding other treatments that have been attempted and failed (such as mediations and physical therapy) help support TENS use. Follow-up visit notes documenting patient benefits from the device (such as decreased medications or improved function) help justify later treatments. The pain must have been present for at least three months.
• Physicians can use either two or four leads with a four-lead TENS unit, depending on the situation. If he orders four leads, the patient record must document why two leads are insufficient.

Check your individual payers' policies to understand their stance on TENS reimbursement.

Example: Blue Cross/Blue Shield of Mississippi considers TENS medically necessary for chronic intractable back pain (cervical, thoracic, or lumbar), where other modalities have failed. The policy outlines that TENS is considered investigational (and therefore is non-reimbursable) for other conditions such as chronic intractable or acute postoperative pain, to relieve pain from labor and vaginal delivery, or to treat dementia.   

Code for the Complete Picture

Initially, Medicare requires TENS to be evaluated on a trial basis for its effectiveness in modulating the patient's pain. Often the physician or physical therapist providing the services will furnish the equipment necessary for assessment. When the patient's condition merits TENS treatment and you are providing the TENS unit, you'll potentially submit supply codes in conjunction with the procedure codes from CPT® or HCPCS.

Heads up: All four Medicare DME LCDs specify that supplies for a TENS unit are included in the rental allowance, so there's no additional allowance for electrodes, lead wires, batteries, etc. If the TENS unit is purchased, the allowance includes lead wires and one month's supply of electrodes, conductive past or gel (if needed), and batteries.

When you can code separately for TENS units and supplies, your choices include:

• A4557 -- Lead wires, (e.g., apnea monitor), per pair
• A4595 -- Electrical stimulator supplies, two leads, per month
• A4630 -- Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient
• E0720 -- Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
• E0730 -- Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation.

Select from these associated procedure codes:

• 64550 -- Application of surface (transcutaneous) neurostimulator
• 97014 -- Application of a modality to 1 or more areas; electrical stimulation (unattended)
• 97032 -- Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.

Note: Code 97014 is not valid for Medicare claims. Report G0283 (Electrical stimulation [unattended] to one or more areas for indications other than wound care, as part of a therapy plan of care) instead.

"If you're setting up TENS in the clinic and not teaching the patient for a home unit, you would use either 97014 or G0283 depending on the payer," explains Rick Gawenda of Gawenda Seminars & Consulting Inc. "If you're instructing the patient on a home TENS unit, you would bill either 97032 or 64550."

Tip: For home instruction, some payers may not recognize 64550, so Gawenda says 97032 may be the better code.

Watch for Potential TENS Changes

Although the June memo paints a bleak picture for reimbursement of many TENS treatments, CMS will continue to reimburse TENS for chronic conditions other than low back pain (such as for patients with chronic or severe postoperative pain).

Continuing study: CMS will continue to fund certain randomized clinical trials of TENS for three years. Patients in these trials must have suffered from low back pain for at least three months, with the pain not resulting from conditions such as metastatic spinal tumors or inflammatory autoimmune disease.