ICD-10-CM Diagnosis Codes
ICD-10-PCS Procedure Codes
CPT® Procedure Codes
HCPCS Supply/DME Codes
ICD-9-CM Diagnosis Codes
Place of Service Codes
UB04 Condition Codes
UB04 Revenue Codes
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Patient controlled analgesia – The postoperative insertion of an intravenous catheter and preprogramming of a patient-activated delivery system to control the first several days of postoperative pain.
Epidural anesthesia – The insertion of a catheter allowing access to the epidural space for the purpose of injecting anesthetic or narcotic medication.
Nerve blocks – Nerve blocks are temporary interruptions of conduction in peripheral nerves or nerve trunks created by the injection of local anesthetic solutions. Somatic and sympathetic nerves may be injected. In the diagnostic mode, this procedure can help differentiate a nerve that is a pathway for the conduction of pain impulses, to determine the type of nerve conducting the pain, to distinguish between central and peripheral origins of pain, and to evaluate the potential benefit of other neurolytic procedures or surgical lysis of a nerve. In a therapeutic mode, the procedure may be used for the treatment of painful conditions that respond to this modality (i.e., celiac block for the treatment of pain related to GI neoplasms), or to prevent pain following procedures.
Endoscopic lysis of adhesions by use of an epiduroscope is a relatively new technique in the treatment of back pain. Approved by the Food and Drug Administration (FDA) in 1996 and marketed by several centers, there is insufficient evidence in peer-reviewed medical literature to support its use at this time.
Pain examination under anesthesia, a two-step procedure to reproduce pain before and after the administration of IV Pentothal, is considered non-covered as it has not been shown to be safe or effective at present. Medicare will consider re-review at a later time if additional peer-reviewed literature is presented.
Pharmacologic challenges for sympathetically maintained pain using IV medications such as lidocaine, phentolamine, carbamazepine or imipramine are considered to be investigational and currently not supported by peer-reviewed literature.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for pain management services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for pain management services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding pain management services are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
- Medicare Benefit Policy Manual – Pub. 100-02: Chapters 1 and 15.
- Medicare National Coverage Determinations Manual – Pub. 100-03.
- Correct Coding Initiative – Medicare Contractor Beneficiary and Provider Communications Manual – Pub. 100-09, Chapter 5.
- Social Security Act (Title XVIII) Standard References, Sections:
- 1862(a)(1)(A) Medically Reasonable & Necessary.
- 1862(a)(1)(D) Investigational or Experimental.
- 1862(a)(7) Screening (Routine Physical Checkups).
- 1833(e) Incomplete Claim.
Jurisdiction “H” Notice:
Jurisdiction “H” comprises the states of Arkansas, Louisiana, Mississippi, Colorado, New Mexico, Oklahoma, and Texas. Novitas is responsible for claims payment and Local Coverage Determination (LCD) development for this jurisdiction. This LCD was created as a part of the legacy transition (8/13/2012 – 11/19/2012); and, is a consolidation of the previous legacy contractors’ policies. Coverage of each LCD begins when the state/contract number combination officially is integrated into the Jurisdiction. On the CMS MCD, this date is known as either the Original Effective Date or the Revision Effective Date. The following table details the official effective dates for each state/contract number combination.
ST Legacy A
J "H" MAC A
J "H" MAC B
AR PBSI: 00520 (J7) Novitas: 07102 08/13/12 LA PBSI: 00528 (J7) Novitas: 07202 08/13/12 AR PBSI: 00020 (J7) Novitas: 07101 08/20/12 LA PBSI: 00233 (J7) Novitas: 07201 08/20/12 MS PBSI: 00233 (J7) Novitas: 07301 08/20/12 MS Cahaba: 00512 (J7) Novitas: 07302 10/22/12 J 4
Trailblazer: 04901 Novitas: 04911 10/29/12 CO Trailblazer: 04101 Novitas: 04111 10/29/12 NM Trailblazer: 04201 Novitas: 04211 10/29/12 OK Trailblazer: 04301 Novitas: 04311 10/29/12 TX Trailblazer: 04401 Novitas: 04411 10/29/12 CO Trailblazer: 04102 Novitas: 04112 11/19/12 NM Trailblazer: 04202 Novitas: 04212 11/19/12 OK Trailblazer: 04302 Novitas: 04312 11/19/12 TX Trailblazer: 04402 Novitas: 04412 11/19/12
Contractor Name(Contractor Number) - Contractor Info
Novitas Solutions, Inc. (07102) - DME Region D
Novitas Solutions, Inc. (07202) - DME Region D
Novitas Solutions, Inc. (07101) - DME Region D
Novitas Solutions, Inc. (07201) - DME Region D
Novitas Solutions, Inc. (07301) - DME Region D
Novitas Solutions, Inc. (07302) - DME Region D
Novitas Solutions, Inc. (04111) - DME Region D
Novitas Solutions, Inc. (04211) - DME Region D
Novitas Solutions, Inc. (04311) - DME Region D
Novitas Solutions, Inc. (04411) - DME Region D
Novitas Solutions, Inc. (04112) - DME Region D
Novitas Solutions, Inc. (04212) - DME Region D
Novitas Solutions, Inc. (04312) - DME Region D
Novitas Solutions, Inc. (04412) - DME Region D
Novitas Solutions, Inc. (04911) - DME Region D
Other Contractor Local Coverage Determinations
“Pain Management,” TrailBlazer LCD, (00400) L17454, (00900) L17444.
“Paravertebral Facet Joint,” TrailBlazer LCD, (00400) L14129, (00900) L14138.
“Paravertebral Facet Joint Block and Facet Joint Denervation,” Noridian Administrative Services, LLC LCD, (CO) L23747.
“Blocks and Destruction of Somatic and Sympathetic Nerves,” Noridian Administrative Services, LLC LCD, (CO) L23692.
“Injection of Spinal Canal,” Noridian Administrative Services, LLC LCD, (CO) L16553.
“Trigger Point Injections,” Noridian Administrative Services, LLC LCD, (CO) L23773.
“Paravertebral Facet Nerve Denervation,” Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L12131.
“Paravertebral Facet Joint Nerve Block,” Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L8151.
“Intercostal Nerve Blocks/Neurolysis,” Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L16131.
“Steroid Injections,” Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L11682 and L11835.
“Local Injections for Trigger Points,” Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L11677 and L11783.
“Epidural Injections,” Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L13444 and L13457.
Novitas Solutions, Inc. – JH Local Coverage Determination (LCD) Consolidation
Narrative Justification – Most Clinically Appropriate LCD
L32122, Surgery: Injections of the Spinal Canal, Cahaba, MS - B
L26743, Pain Management, TrailBlazer, CO, NM, OK, TX – A/B
L8097, Local Injections for Trigger Points, Pinnacle, AR - B
L31008, Epidural Injections, Pinnacle, LA, MS - A
L13483, Epidural Injections, Pinnacle, LA - B
L21874, Epidural Injections, Pinnacle, AR - A
L13423, Epidural Injections, Pinnacle, AR – B
L31034, Local Injections for Trigger Points, Pinnacle, LA, MS – A
L11955, Local Injections for Trigger Points, Pinnacle, LA – B
L18767, Local Injections for Trigger Points, Pinnacle, AR – A
L30647, Surgery: Trigger Point Injections, Cahaba, MS - B
LCD L26743 from TrailBlazer is the most comprehensive of all the LCDs reviewed given the significant overlap between LCDs. L26743 includes trigger point injections, epidural injections, nerve blocks, and other miscellaneous spinal injections covered in the other LCDs. L26743 has a well written Indications/Limitations sections and the most comprehensive list of CPT codes. The Sources of Information and Basis for Decision is not present in L26743 as TrailBlazer adopted the LCD from another LCD during the J4 transition. L26743 is the most clinically appropriate LCD.
Advisory Committee Meeting Notes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.12 - Hospital Inpatient (Medicare Part B only)
13 - Hospital Outpatient
18 - Hospital - Swing Beds
21 - Skilled Nursing - Inpatient (Including Medicare Part A)
22 - Skilled Nursing - Inpatient (Medicare Part B only)
23 - Skilled Nursing - Outpatient
71 - Clinic - Rural Health
75 - Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
77 - Clinic - Federally Qualified Health Center (FQHC)
83 - Ambulatory Surgery Center
85 - Critical Access Hospital
Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.0360 - Operating Room Services - General Classification
0450 - Emergency Room - General Classification
0490 - Ambulatory Surgical Care - General Classification
0499 - Ambulatory Surgical Care - Other Ambulatory Surgical
0500 - Outpatient Services - General Classification
0509 - Outpatient Services - Other Outpatient
0510 - Clinic - General Classification
0511 - Clinic - Chronic Pain Center
0512 - Clinic - Dental Clinic
0513 - Clinic - Psychiatric Clinic
0514 - Clinic - OB-GYN Clinic
0515 - Clinic - Pediatric Clinic
0516 - Clinic - Urgent Care Clinic
0517 - Clinic - Family Practice Clinic
0519 - Clinic - Other Clinic
0520 - Free-Standing Clinic - General Classification
0521 - Free-Standing Clinic - Clinic Visit by Member to RHC/FQHC
0522 - Free-Standing Clinic - Home Visit by RHC/FQHC Practitioner
0523 - Free-Standing Clinic - Family Practice Clinic
0524 - Free-Standing Clinic - Visit by RHC/FQHC Practitioner to a Member in a Covered Part A Stay at SNF
0525 - Free-Standing Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF (not in a Covered Part A Stay) or NF or ICF MR or Other Residential Facility
0526 - Free-Standing Clinic - Urgent Care Clinic
0527 - Free-Standing Clinic - Visiting Nurse Service(s) to a Member's Home when in a Home Health Shortage Area
0528 - Free-Standing Clinic - Visit by RHC/FQHC Practitioner to Other non-RHC/FQHC site (e.g., Scene of Accident)
0529 - Free-Standing Clinic - Other Freestanding Clinic
0761 - Specialty Services - Treatment Room
Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. 62263 62264 62280 62281 62282 62310 62311 62318 62319 64400 64402 64405 64408 64410 64412 64413 64415 64417 64418 64420 64421 64425 64430 64435 64445 64450 64483 64484 64505 64508 64510 64520 64530 64633 64634 64635 64636 77003
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 64633, 64634, 64635 and 64636.
Note: Medicare is only establishing limited coverage for CPT codes 64633, 64634, 64635 and 64636 as listed below. All other CPT codes included in this policy will not be subject to limited coverage at this time because there are numerous reasonable and necessary conditions that warrant their application. An appropriate ICD-9-CM code must be submitted with each claim, coded to the highest level of specificity for that date of service.
721.0 721.1 721.2 721.3 721.41 721.42 721.90 721.91 722.4 722.51 722.52 722.6 722.70 722.71 722.72 722.73 722.81 722.82 722.83 733.13 738.4