LCD/NCD Portal
Automated World Health
Local Coverage Determination (LCD) for Endoscopic and Percutaneous Lysis of
Epidural Adhesions (L28948)
Contractor Information
Contractor Name First Coast Service Options, Inc.
Contractor Number 09101
Contractor Type MAC - Part A
LCD Information
Document Information
LCD ID Number L28948
LCD Title Endoscopic and Percutaneous Lysis of Epidural Adhesions
Contractor's Determination Number A62263
Primary Geographic Jurisdiction Florida
Oversight Region Region IV
AMA CPT/ADA CDT Copyright Statement
CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.
Original Determination Effective Date
For services performed on or after 02/16/2009
Original Determination Ending Date
Revision Effective Date
For services performed on or after 10/01/2010
Revision Ending Date
CMS National Coverage Policy
Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources:
N/A
Indications and Limitations of Coverage and/or Medical Necessity
Endoscopic epidural lysis of adhesions (also known as endoscopic lysis) and percutaneous epidural lysis of adhesions (also referred to as epidural neuroplasty or epidural adhesiolysis) are interventional pain management techniques that are used to treat chronic cervical, lumbar, and thoracic pain. The basis for performing this procedure is the premise that fibrous adhesions (scar tissue) develops after surgery, trauma, and/or inflammation that compounds pain associated with the nerve root by fixing it in one position and thus increasing the susceptibility of the nerve root to tension or compression. This scar tissue also prevents the direct application of medications to relieve pain (local anesthetics and corticosteroids) to the problem area. The goal of the procedure is to break down these fibrous adhesions to allow for delivery of high concentrations of injected drugs to the target area and free the nerve from mechanical tension/compression. The procedure usually involves adhesiolysis procedures performed over a 1-3 day period (CPT code 62263 – more than 2 days or 62264 – one day. Adhesiolysis can be accomplished by solution injection (commonly hypertonic saline and/or hyaluronidase) and/or by mechanical means (by maneuvering a specially designed epidural catheter or epiduroscope).
Medicare will consider the use of endoscopic and percutaneous lysis of epidural adhesions to be medically reasonable and necessary in the treatment of chronic refractory cervical, lumbar, and thoracic pain that has failed to respond to more conservative treatment measures. Conservative treatment may include local heat, traction, nonsteroidal anti-inflammatory medications, and anesthetic and/or steroid epidural injections. The chronic refractory low back pain may be secondary to post lumbar laminectomy syndrome, intervertebral lumbar disc disruption, lumbar epidural adhesions, and/or lumbar degenerative disc disorder. It is not expected that services will exceed one every six months to the same anatomical region. Services exceeding one every six months may be subject to medical review.
Coding Information
Bill Type Codes:
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.
013x Hospital Outpatient 085x Critical Access Hospital
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
0360 Operating Room Services - General Classification
CPT/HCPCS Codes
64999 Unlisted procedure, nervous system (Endoscopic lysis of epidural adhesions with the epiduroscope) PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC
62263 SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION
(INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 2 OR MORE DAYS
PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC 62264 SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION
(INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 1 DAY
64999 UNLISTED PROCEDURE, NERVOUS SYSTEM
ICD-9 Codes that Support Medical Necessity
722.0 DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY
722.10 DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY
722.4 DEGENERATION OF CERVICAL INTERVERTEBRAL DISC
722.52 DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC
722.73 INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION
722.81 POSTLAMINECTOMY SYNDROME OF CERVICAL REGION
722.82 POSTLAMINECTOMY SYNDROME OF THORACIC REGION
722.83 POSTLAMINECTOMY SYNDROME OF LUMBAR REGION
723.0 SPINAL STENOSIS IN CERVICAL REGION
723.4 BRACHIAL NEURITIS OR RADICULITIS NOS
724.1 SPINAL STENOSIS OF THORACIC REGION
724.2 SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION
724.3 SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION
724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED
Diagnoses that Support Medical Necessity N/A
ICD-9 Codes that DO NOT Support Medical Necessity N/A
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity N/A
General Information
Documentations Requirements
Medical record documentation maintained by the performing physician must clearly indicate the medical necessity of the service being billed. In addition, documentation that the service was performed must be included in the patient’s medical record. This information is normally found in the office/progress notes, hospital notes, and/or procedure report.
In addition, the medical record should clearly document the nature of the chronic refractory low back pain. This should include the location, intensity, type of pain present, and contributing factors (if any), duration of condition, and treatment regimes that have been utilized. Documentation should demonstrate failure of more conservative management in the treatment of the patient’s condition. This more conservative treatment may include local
heat, traction, nonsteroidal anti-inflammatory medications, and anesthetic and/or steroid epidural injections.
Appendices
Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they
may be subject to review for medical necessity.
Sources of Information and Basis for Decision
Boswell, M. V., Trescot, A. M., et al Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 10:7 pp 48-51.
Manchikanti, l., Heavner, J., Boswell, M.V. (2007) Endoscopic lumbar epidural adhesions. Intervential Techniques in Chronic Spinal Pain. Pp 507-526
Manchikanti, L., Boswell, M.V., et al. A randomized controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain. BMC Anesthesiology 2005 (5) 10
Manchikanti, L., Singh, V (2007) Pecutaneous lysis of lumbar epidural adhesions. Interventional Techniques in Chronic Spinal Pain. Pp479-506
Racz, G.B., Heavner, J.E., Trescot, A. (2008) Percutaneous lysis of epidural adhesions-evidence for safety and efficacy. Pain Practice 8 (4) 277-286.
Trescot AM, Chopra P, Abdi S, Datta S, Schultz DM. Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: An update. Pain Physician 2007; 10: 129-146.
http://www.painphysicianjournal.com/2007/january/2007;10;129-146.pdf Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from The Florida Society of Anesthesiologists, Florida Society of Physical Medicine and
Rehabilitation, and the Florida Neurosurgical Society.
Start Date of Comment Period
End Date of Comment Period
Start Date of Notice Period 10/01/2010
Revision History Number 2
Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A
Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010
LCR A2010-050
September 2010 Bulletin
Explanation of Revision: Annual 2011 ICD-9-CM Update. Added ICD-9-CM code 724.03. Revised descriptor for ICD-9-CM code 724.02. The effective date of this revision is based on date of service.
Revision Number:1
Start Date of Comment Period:06/01/2009 Start Date of Notice Period:08/15/2009 Revised Effective Date: 09/30/2009
LCR A2009-074
August 2009 Bulletin
Explanation of Revision: LCD revised to include endoscopic lysis of epidural adhesions. Title of LCD changed to include “Endoscopic” lysis of epidural adhesions. Updated “Sources of Information and Basis for Decision” section. Updated “CPT/HCPCS code” section to include 64999 [Unlisted procedure, nervous system] to be reported when billing for endoscopic lysis of epidural adhesions. Updated the “ICD-9 Codes that Support Medical Necessity” section to include ICD-9-CM codes 722.0, 722.4, 722.81, 722.82, 723.0, 723.4, 724.01 and 724.02. Updated Coding Guidelines. Deleted Type of Bill Code 21x. The effective date of this revision is based on date of service.
Revision Number:Original
Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009
LCR A2009-034FL
December 2008 Bulletin
This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).
For Florida (00090) this LCD (L28948) replaces LCD L1109 as the policy in notice. This document (L28948) is effective on 02/16/2009.
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 85 was changed 8/1/2010 - The description for Revenue code 0360 was changed
09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.
Reason for Change
Related Documents
This LCD has no Related Documents.
LCD Attachments
Coding Guidelines
Draft LCD Comment Summary
Coding Guidelines effective 09/30/2009
All Versions
Updated on 09/17/2010 with effective dates 10/01/2010 - N/A Updated on 09/15/2010 with effective dates 10/01/2010 - N/A Updated on 09/06/2010 with effective dates 09/30/2009 - 09/30/2010 Updated on 08/01/2010 with effective dates 09/30/2009 - N/A Updated on 08/01/2010 with effective dates 09/30/2009 - N/A Updated on 08/17/2009 with effective dates 09/30/2009 - N/A Updated on 08/07/2009 with effective dates 09/30/2009 - N/A Updated on 11/30/2008 with effective dates 02/16/2009 - N/A