2016 HF10 THERAPY REIMBURSEMENT REFERENCE GUIDE

HF10 therapy, delivered by the Nevro Senza System, is a new high-frequency spinal cord stimulation technology
designed to aid in the management of chronic intractable pain of the trunk/limbs, including unilateral or bilateral pain
associated with the following: Failed Back Surgery Syndrome (FBSS), intractable low back and leg pain.

REIMBURSEMENT SUPPORT LINE 1-888-895-8104

Physician Coding and Payment
The following CPT codes are provided as a guide for physician reporting. Actual code(s) billed should reflect the services
provided to each individual patient in the office (non-facility) or hospital (facility) setting. The Medicare fee schedules
listed are a national average and have not been geographically adjusted.
Procedure

CPT Code1

63650*
63655*
Implant

63685*
63663*

Revision

63664*

63688*
63661*
63662*
Removal

63688*

Description

Percutaneous implantation of neurostimulator electrode array, epidural

Laminectomy for implantation of neurostimulator electrodes,
plate/paddle, epidural
Insertion or replacement of spinal neurostimulator pulse generator or
receiver, direct or inductive coupling
Revision including replacement, when performed, of spinal
neurostimulator electrode percutaneous array(s), including fluoroscopy,
when performed
Revision including replacement, when performed, of spinal
neurostimulator electrode plate-paddle(s) via laminotomy or
laminectomy, including fluoroscopy, when performed
Revision or removal of implanted spinal neurostimulator pulse generator
or receiver
Removal of spinal neurostimulator electrode percutaneous array(s),
including fluoroscopy, when performed
Removal of spinal neurostimulator electrode plate/paddle(s) placed via
laminotomy or laminectomy, including fluoroscopy, when performed
Revision or removal of implanted spinal neurostimulator pulse generator
or receiver

Medicare
NonFacility
National
Average2
$1,370
N/A

Medicare
Facility
National
Average2

Global
Period2

$430
$860

10
90

N/A

$381

10

$818

$472

10

N/A

$896

90

N/A

$383

10

$596

$333

10

N/A

$872

90

N/A

$383

10

* Standard multiple procedure rules apply: When two or more eligible procedures are performed together on the same date of service, the highest paid code is reimbursed
at 100% of the fee schedule; each additional code is reimbursed at 50% of the fee schedule.

IPG Analysis & Programming: The AMA states that simple programming (95971) is defined as changes to three or fewer parameters described in the
programming codes below. Complex programming (95972) includes changes to more than three parameters described below.1

New for 2016

Disclaimer:

The information contained in this document is for informational purposes only and is current as of January, 2016. It is always the responsibility of the provider to determine if the services
actually provided are accurately described by any specific code(s) and to report services consistent with specific payer requirements. Nothing in this guide guarantees that payment or
coverage will be received. This information is subject to change at any time, and Nevro, Inc. strongly recommends that you consult your payer organization with regard to its reimbursement
policies. In all cases, services billed must be medically necessary, actually performed as reported and appropriately documented.

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2016 HF10 THERAPY REIMBURSEMENT REFERENCE GUIDE

Procedure

CPT Code1

Analysis &
Programming

95970

95971

95972

Description

Electronic analysis of implanted neurostimulator pulse generator system

(eg, rate, pulse amplitude, pulse duration, configuration of wave form,
battery status, electrode selectability, output modulation, cycling,
impedance and patient compliance measurements); simple or complex
brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, sacral
nerve, neuromuscular) neurostimulator pulse generator/transmitter,
without reprogramming
simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve,
neuromuscular neurostimulator pulse generator/transmitter, with
intraoperative or subsequent programming
complex spinal cord, or peripheral (ie, peripheral nerve, sacral
nerve, neuromuscular) (except cranial nerve) neurostimulator pulse
generator/transmitter, with intraoperative or subsequent
programming

Medicare
NonFacility
National
Average2
$69

Medicare
Facility
National
Average2

Global
Period2

$25

XXX7

$51

$42

XXX7

$59

$43

XXX7

Physician Modifiers
Modifiers are appended to CPT codes to indicate to a payer that a service or procedure has been altered by specific
circumstances, but do not ensure payment. In all cases, documentation must support the use of any modifiers reported on
claims, and providers should be prepared to submit their documentation to the payers to justify any potential increases in
payment.
Modifier 1,3
- 22

Description
Increased procedural services

-52

Reduced services

-53

Discontinued procedure

-58

Staged or related procedure or service by the same physician

or other qualified health care professional during the
postoperative period

Notes4
Used to identify procedures where additional work, time and
complexity was required.
Report this modifier when a service or procedure is partially
reduced or eliminated at the physicians discretion.
Use this modifier when a surgical or diagnostic procedure is
terminated, prior to administration of anesthesia or surgical
preparation, due to extenuating circumstances or those that
threaten the well-being of the patient.
Report this modifier during the post-op period if a procedure or
service was performed was: a) planned prospectively at the time
of the original procedure (staged); b) more extensive than the
original procedure; or c) for therapy following a diagnostic
surgical procedure.

New for 2016

Disclaimer:

The information contained in this document is for informational purposes only and is current as of January, 2016. It is always the responsibility of the provider to determine if the services
actually provided are accurately described by any specific code(s) and to report services consistent with specific payer requirements. Nothing in this guide guarantees that payment or
coverage will be received. This information is subject to change at any time, and Nevro, Inc. strongly recommends that you consult your payer organization with regard to its reimbursement
policies. In all cases, services billed must be medically necessary, actually performed as reported and appropriately documented.

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2016 HF10 THERAPY REIMBURSEMENT REFERENCE GUIDE

Distinct procedural service
-XE5
-XP5
-XS5
-XU5

-59

-62
Modifier 1,3
-76
-78

-80
-81
-82

Also append the appropriate subset modifier (XE, XP, XS, XU)
below.
Separate encounter, a service that is distinct because it occurred during a separate encounter
Separate practitioner, a service that is distinct because it was performed by a different practitioner
Separate structure, a service that is distinct because it was performed on a separate organ/structure
Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main
service
Two surgeons
Identifies the case where two primary surgeons perform distinct
parts of a single procedure.
Description
Notes4
Repeat procedure or service by the same physician or other
Report this modifier when a procedure or service was repeated
qualified health care professional
subsequent to the original procedure or service.
Unplanned return to the operating /procedure room by the
Used when another procedure was performed during the post-op
same physician or other qualified health care professional
period of the initial procedure.
following initial procedure for a related procedure during the
postoperative period
Assistant surgeon
Used to identify a surgeon who actively assists in a procedure but
does not perform distinct parts of the primary procedure.
Minimum assistant surgeon
Reported when the services of an assistant surgeon are required
for a relatively short period of time.
Assistant surgeon (when qualified resident surgeon not
Report this modifier when a qualified surgeon is not readily
available)
available.

Device
Lead: 8contact
External
Recharger
Remote
Control
(patient
programme
r)
Pulse
Generator
Medicare
Device
HCPC
Codes
Leads

HCPCS Code9
L8680

Description
Implantable neurostimulator electrode, each

L8689

External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

L8681

Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement
only

L8687

Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

C1778
C1897

Extension

C1883

Lead, neurostimulator (implantable)

Lead, neurostimulator, test kit (implantable)
Adaptor/extension, pacing lead or neurostimulator lead (implantable)

New for 2016

Disclaimer:

The information contained in this document is for informational purposes only and is current as of January, 2016. It is always the responsibility of the provider to determine if the services
actually provided are accurately described by any specific code(s) and to report services consistent with specific payer requirements. Nothing in this guide guarantees that payment or
coverage will be received. This information is subject to change at any time, and Nevro, Inc. strongly recommends that you consult your payer organization with regard to its reimbursement
policies. In all cases, services billed must be medically necessary, actually performed as reported and appropriately documented.

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2016 HF10 THERAPY REIMBURSEMENT REFERENCE GUIDE

Pulse
Generator
Patient
Programme
r

C1822 1

Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system

C1787

Patient programmer, neurostimulator

Medicare Coverage Determinations

Medicare has a National Coverage Determination (NCD) which allows for coverage of spinal cord stimulation when the
following criteria6 are met:

The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic
intractable pain;
With respect to the previous criteria, other treatment modalities (pharmacological, surgical, physical or
psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or
contraindicated for the given patient;
Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to
implantation. Such screening must include psychological, as well as physical evaluation;
All the facilities, equipment and professional and support personnel required for the proper diagnosis, treatment
training, and follow-up of the patient (including that required to satisfy the previous criteria must be available;
and,
Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation.

In addition, some local Medicare Administrative Contractors (MACs) may require additional coverage criteria through their
local policies (LCDs). It is advised the providers check with their individual MACs to confirm the coverage criteria in their
state.

1
1

New for 2016

New for 2016

Disclaimer:

The information contained in this document is for informational purposes only and is current as of January, 2016. It is always the responsibility of the provider to determine if the services
actually provided are accurately described by any specific code(s) and to report services consistent with specific payer requirements. Nothing in this guide guarantees that payment or
coverage will be received. This information is subject to change at any time, and Nevro, Inc. strongly recommends that you consult your payer organization with regard to its reimbursement
policies. In all cases, services billed must be medically necessary, actually performed as reported and appropriately documented.

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2016 HF10 THERAPY REIMBURSEMENT REFERENCE GUIDE

References:
Current Procedural Terminology 2016, American Medical Association. Chicago, IL 2015. CPT is a registered trademark of the American Medical Association. Current Procedural Terminology
(CPT) is copyright 2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.
2 Medicare Physician Fee Schedule Final Rule, Federal Register (80 Fed Reg, No. 220) November 16, 2015, 42 CFR Parts 405, 410 and 411 et al.
1

HCPCS Level II, 2016 Expert. Ingenix, St. Anthony Publishing/Medicode. Salt Lake City, 2015.
Coding With Modifiers, A Guide to Correct CPT And HCPCS Level II Modifier Usage, Second Edition. American Medical Association. Chicago, IL 2014.
5 Specific Modifiers for Distinct Procedural Services. MLM Matters Number MM8863, effective January 1, 2015. Related Change Request #8863, released August 15, 2014.
6 National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7). Centers for Medicare and Medicaid Services. Benefit Category: Prosthetic Devices. Effective August 7, 1995.
7 XXX: The global concept does not apply to the code.
8 ZZZ: Code related to another service that is always included in the global period of the other service.
9 HCPCS Level II, 2016 Expert. Ingenix, St. Anthony Publishing/Medicode. Salt Lake City, 2015.
3
4

New for 2016

Disclaimer:

The information contained in this document is for informational purposes only and is current as of January, 2016. It is always the responsibility of the provider to determine if the services
actually provided are accurately described by any specific code(s) and to report services consistent with specific payer requirements. Nothing in this guide guarantees that payment or
coverage will be received. This information is subject to change at any time, and Nevro, Inc. strongly recommends that you consult your payer organization with regard to its reimbursement
policies. In all cases, services billed must be medically necessary, actually performed as reported and appropriately documented.

2015040 Rev. C