A recent report by the Department of Health and Human Services Office of Inspector General shines a light on significant billing issues for neurostimulator implantation surgeries.
OIG Findings
According to the OIG’s report, 40 percent of healthcare providers did not meet Medicare documentation requirements when billing for neurostimulator implantation surgeries, resulting in more than $636 million in unallowable Medicare payments and $54 million in unnecessary copays and deductibles during 2016 and 2017.
During the time period covered by the audit, neurostimulator implantation surgery claims did not require prior authorization and were not subject to prepayment review. In the meantime, however, the Centers for Medicare and Medicaid Services (CMS) has begun requiring prior authorizations for outpatient implanted spinal neurostimulators (not including claims for Parkinson’s disease or seizure disorders) beginning July 1, 2021, which was among the OIG recommendations.
CMS Response
CMS also has begun implementing other OIG recommendations, like instructing Medicare Administrative Contractors (MACs) to recover related Medicare overpayments and to notify providers with potential overpayments to exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule. As well, CMS has already conducted provider outreach and education regarding the Medicare coverage requirements for neurostimulator implantation surgeries beginning last summer.
However, CMS said that its prior authorization authority does not extend to inpatient services, such as implantation surgeries for Parkinson’s disease and seizure disorders, which was another OIG recommendation.
Documentation Requirements
Documentation requirements for Implanted Spinal Neurostimulators are included in the Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational Guide (page 20).
General Documentation Requirements for trial or permanent Implanted Spinal Neurostimulators:
- Indicate if this request is for a trial or permanent placement
- Physician office notes including:
- Condition requiring procedure
- Physical examination
- Treatments tried and failed including but are not limited to Spine surgery, Physical therapy, Medications, Injections, and Psychological therapy
- Documentation of appropriate psychological evaluation3
- For permanent placement, include all the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s). A successful trial should be associated with at least 50% reduction of target pain or 50% reduction of analgesic medications.
Learn More
For more information about the OIG’s findings on neurostimulator implantation surgeries and CMS prior authorization requirements, check out these resources:
- The OIG’s report, MEDICARE OVERPAID MORE THAN $636 MILLION FOR NEUROSTIMULATOR IMPLANTATION SURGERIES
- MLN Connects from June 16, 2022
- MLN Connects from June 10, 2021
- Prior Authorization and Pre-Claim Review Initiatives webpage
- Section XVII Calendar Year 2021 Hospital Outpatient Prospective Payment System final rule
- Section 6.3.2.2 Prior Authorization Program for Certain Hospital Outpatient Department Services (PDF) operational guide
- 2021 Final List of Outpatient Department Services That Require Prior Authorization (PDF)
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