Reimbursement Details

Our breathing pacemaker system has full premarket approval from the US FDA for adult and pediatric patients. It is approved for reimbursement under Medicare and is therefore covered for reimbursement by most private and government insurance plans around the world. The equipment is sometimes indexed as a phrenic nerve pacemaker, diaphragm pacemaker, or electrophrenic respiration. A proforma invoice is available upon request.

Systems are available in a variety of configurations depending on the patient's needs. Additionally, custom components and conversions from other systems are also available. Please contact ABD for an appropriate price quotation.

ABD has compiled this coding information for your convenience. It is always the provider's responsibility to determine coverage and submit appropriate codes, modifiers, and charges for the services to be rendered. Please contact the patient's local carrier/payer for interpretation of appropriate coverage and coding policies.

Medicare Coverage

Phrenic nerve stimulation is covered for reimbursement under Medicare. Almost all state medical assistance programs and most private insurers use the Medicare guidelines to determine coverage. The relevant section of the Medicare National Coverage Determinations Manual reads as follows:

160.19 - Phrenic Nerve Stimulator
(Rev. 1, 10-03-03)
CIM 65-13

The implantation of a phrenic nerve stimulator is covered for selected patients with partial or complete respiratory insufficiency.

The phrenic nerve stimulator provides electrical stimulation of the patient's phrenic nerve to contract the diaphragm rhythmically and produce breathing in patients who have hypoventilation (a state in which an abnormally low amount of air enters the lungs). The device has been used successfully to treat hypoventilation caused by a variety of conditions, including respiratory paralysis resulting from lesions of the brain stem and cervical spinal cord and chronic pulmonary disease with ventilatory insufficiency. The phrenic nerve stimulator is intended to be an alternative to management of the patients with respiratory insufficiency who are dependent upon the usual therapy of intermittent or permanent use of a mechanical ventilator as well as mainentance of a tracheostomy stoma.

However, an implanted phrenic nerve stimulator can be effective only if the patient has an intact phrenic nerve and diaphragm. Moreover, nerve injury may occur during the surgical procedure and if sufficient injury is incurred, the device will not prove useful to the patient. Consequently, it is possible for such a device to be indicated for a patient, but due to injury sustained during implant, fail to assist the patient, resulting in a return to the use of mechanical ventilation.

Cross reference to §160.7, "Electrical Nerve Stimulation."

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ICD-9-CM Code

34.85

Implantation of a diaphragmatic pacemaker

Common Diagnosis Codes

V46.11	Dependence on Respirator, Status (ICD-10, Z99.11)
327.24	Idiopathic sleep related nonobstructive alveolar hypoventilation (ICD-10, G47.34))
327.25	Congenital central alveolar hypoventilation syndrome (ICD-10, G47.35)
344.01	C1-C4, Complete quadriplegia (ICD-10, G82.51)
344.02	C1-C4, Partial quadriplegia (ICD-10, G82.52)
356.8	Other specified idiopathic peripheral neuropathy (ICD-10, G60.8)
519.4	Diaphragm paralysis (ICD-10, J98.6)
748.8	Other specified congenital abnormalities of respiratory system (ICD-10, Q34.8)

MS-DRG Codes

163,164,165	Major chest procedures (with MCC, with CC, without CC or MCC)
907,908,909	Other OR procedures for injuries (with MCC, with CC, without CC or MCC)
957,958,959	Extensive OR procedure unrelated to principal diagnosis (with MCC, with CC, without CC or MCC)
981,982,983	Extensive OR procedure unrelated to principal diagnosis (with MCC, with CC, without CC or MCC)

CPT Codes

64575	Incision for implantation of neurostimulator electrode array, peripheral nerve (CMS recommended replacement for Code 64577 which is deleted as of 1/1/2012). Use with HCPCS C1778.
64590	Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling. Use with HCPCS C1767.
64595	Revision or removal of peripheral neurostimulator electrodes. If a revision procedure, use with HCPCS C1778.
64595	Revision or removal of peripheral neurostimulator pulse generator or receiver. Use with HCPCS C1767.

HCPCS Codes

C1778	Lead, neurostimulator (implantable). Use with CPT 64575 or 64585.
C1816	Receiver and/or transmitter, neurostimulator). Use with CPT 64590 or 64595

A summary of commonly billed codes is available for download as a PDF file by clicking here. Adobe Reader is required to view PDF files.