Noridian has issued new guidance on SCS documentation and compliance.  The OIG found that 40% of providers, in both HOPDs and ASCs, did not comply with Medicare requirements when they billed for SCS, with overpayments of $636 million.  (https://oig.hhs.gov/oas/reports/region1/11800500.pdf). 

This study matters because Noridian will in turn audit providers and ask for repayment if documentation deficiencies are found.

Noridian has taken steps to help providers comply with documentation requirements and prior authorization.  Prior authorization is for HOPD only. Most important is 6.3.2.2, which deals with SCS, shown below.

The relevant webpage is Prior Authorization and Pre-Claim Review Initiatives webpage for HOPD services.

(https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services)

6.3.2.2 - Implanted Spinal Neurostimulators

Providers who plan to perform both the trial and permanent implantation procedures using CPT 63650 in the hospital OPD will only be required to submit a PAR for the trial procedure. To avoid a claim denial, providers must place the Unique Tracking Number (UTN) received for the trial procedure on the claim submitted for the permanent implantation procedure. When the trial is rendered in a setting other than hospital OPD, providers will need to request PA for CPT 63650 as part of the permanent implantation procedure in the hospital OPD.

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 Psychological therapy

  • Documentation of appropriate psychological evaluation

  • 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.