SCS multiple procedure reduction

[Logano2230]

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Hello:

I’m in a hospital employed wRVU-based compensation model. I’ve been reviewing my coding and the system is applying a 50% reduction in wRVU to 63685 when doing an SCS implant.

My understanding was that 63650x2 and 63685 are submitted without a -51 modifier. Do any know if Medicare/payers are subjecting the 63685 payment to a multiple procedures reduction?

Thanks

 

[gdub25]

The hospital gets paid one lump sum for the procedure, they are not paid per CPT code. The doctor will bill and get paid the professional fee for 63650 x2 plus the 63685. If getting paid by RVU you should get full credit for all codes.

 

[Logano2230]

I’m sorry I should further clarify. The implants are being performed in an ASC and we separately bill the professional fee.

 

[gdub25]

ASCs sometimes bill as Hosptial fyi, not sure if that’s the case or not in your situation. Either way though, I you as the provided would be billing for the professional fee only and it should be as I said, full payment for 63650 x2 and 63685. Some of these hosptial guys can chime in and maybe depending on the hospital you work for they may reduce RVU payment but if in private practice and just billing insurance directly you get paid for each code.

 

[BobBarker]

I always got paid the full amount for each code when I was hospital employed. It was around 20 units. Quite a lot.

 

[doctoroxygen]

Per CMS (per my coders), 63685 is subject to Multiple Procedure Reduction and 63650 is subject to modifier 51.

 

[BobBarker]

Never believe your billers and coders.


Novitas SCS billing

 

[SSdoc33]

they probably think this is bilateral b/c there are 2x 63650.

for a bilateral TFESI, you often get only half of the RVUs of the contralateral side

this is different, and you should make a stink about it

 

[gdub25]

Correct. Bilateral procedures will reimburse half for the second side, but 63650 is not bilateral.

For background and context, I started and run a billing service for private clinics and ASCs specifically in pain management because I felt I could do a better job than what I was paying for. Too many times these companies or hosptial billers don’t understand what they’re billing. To them it’s just codes on a claim.

 

[BobBarker]

@gdub25

Do you also offer a service that provides competent, hardworking medical assistants???

 

[MitchLevi]

I'm in conversations as we speak about SCS billing.

63650
63650-59

That's two leads. Doesn't that pay 100% for both lead?

 

[RoloTomassi]

I'm in conversations as we speak about SCS billing.

63650
63650-59

That's two leads. Doesn't that pay 100% for both lead?

I've always done 63650 x2

 

[MitchLevi]

I've always done 63650 x2

I'm discussing it now, and it's 50% of the second lead.

 

[RoloTomassi]

I'm discussing it now, and it's 50% of the second lead.

I have to check but I think if you bill 2 units you get paid 2 units. Maybe it's because you bill one with -59. Like how you'd get 50% on a knee + hip with -59, which would be appropriate because different body sites but not 2 leads same site same time

 

[MitchLevi]

My argument to my billers. If you bill 63650 and 63650-59 it's 100% for both leads. That's my understanding, but that's not what we're being told.

 

[BobBarker]

Novitas says it is 63650 and 63650-59 so that is probably the correct coding for all Medicare groups. So if they are using those codes, what comes in, comes in. You aren’t going to get Medicare to change what they pay you. You can only code correctly/ideally.

 

[MitchLevi]

Novitas says it is 63650 and 63650-59 so that is probably the correct coding for all Medicare groups. So if they are using those codes, what comes in, comes in. You aren’t going to get Medicare to change what they pay you. You can only code correctly/ideally.

Dang it! My shoes are like...Round and muted at the toes.

 

[achacha]

Did you ever get this fixed? my billers are telling me the same thing and i need proof they are wrong. can anyone point me to documents supporting getting paid 2x 63650?

 

[PMROralBoards]

It depends on the Medicare payor in your state. We have noridian. They will only pay 50% of the second lead. Applies to scs and PNS. You can call them directly to confirm usually.

 

[1 Up]

When I first started practicing, I noticed the 50% reduction for the 2nd lead, and the IPG. Spoke to Medtronic billing, where they basically said that was correct. I downloaded the fee schedule to confirm, and found that 63650 is in fact clearly listed as "standard payment adjustment for multiple procedures" (50% reduction for additional codes during the same procedure session). Sorry.

 

[Logano2230]

Ultimately, my system decided to follow our local Medicare MAC (CGS) when determining wRVU for implants. While many other payors are reimbursing fully, CGS pays both 63650 in full and then 63685 gets cut in half. It creates a strange scenario where a trial is 14.3 wRVU and an implant is 16.9 wRVU.