Intracept Billing, Coding & Reimbursement - The Intracept Procedure by Relievant

​Indications for Use and Reimbursement Information for the Intracept Procedure

The Intracept Procedure, developed by Relievant Medsystems, is a groundbreaking treatment for chronic low back pain that originates from the vertebral endplates, also known as vertebrogenic pain. This minimally invasive procedure targets the basivertebral nerve (BVN) within the vertebral body to alleviate pain. Given the innovative nature of the Intracept Procedure, accurate billing and coding, understanding insurance coverage, and navigating the prior authorization process are crucial for healthcare providers to ensure proper reimbursement and patient access. This comprehensive guide will delve into each of these aspects in detail.
1. Understanding the Intracept ProcedureThe Intracept Procedure involves the thermal ablation of the basivertebral nerve, which is responsible for transmitting pain signals from the vertebral endplates. This procedure has shown significant efficacy in reducing pain and improving function in patients with chronic low back pain who have not responded to conservative treatments.
Clinical Indications:

• Chronic low back pain of at least six months duration.
• Failure to respond to at least six months of conservative care.
• MRI-confirmed Modic Type 1 or Type 2 changes at the vertebral endplates.

Clinical Evidence:

• Supported by over 20 years of research.
• Demonstrated in two Level 1 randomized controlled trials.
• Improvements in pain and function have been shown to be maintained long-term post-procedure​ (ORTHOWORLD)​​ (Intracept by Relievant)​.

2. Billing and Coding for the Intracept ProcedureCPT Codes: The American Medical Association (AMA) has established specific Category I Current Procedural Terminology (CPT) codes for the Intracept Procedure, effective January 1, 2022:

• 64628: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies, lumbar or sacral.
• +64629: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral.

Indications for Use:
The Intracept Intraosseous Nerve Ablation System is a specialized medical device used for treating chronic low back pain that originates from the vertebral endplates. This condition is known as vertebrogenic pain. Here’s a detailed breakdown of the indications and procedural specifics:

• Targeted Vertebrae: The procedure targets the basivertebral nerves located in the L3 through S1 vertebrae.
• Pain Duration: It is intended for patients who have experienced chronic low back pain for a minimum of six months.
• Conservative Care Failure: The procedure is specifically for those who have not responded to at least six months of conservative treatments, such as physical therapy, medications, or injections.
• MRI Findings: Candidates for the Intracept Procedure must have MRI findings that show Type 1 or Type 2 Modic changes. These changes can include:
  • Type 1 Modic Changes: Indicate inflammation and edema. On MRI, these appear as hypo-intensive signals on T1-weighted images and hyper-intensive signals on T2-weighted images.
  • Type 2 Modic Changes: Indicate fat replacement of the bone marrow. These appear as hyper-intensive signals on both T1- and T2-weighted images.

These Modic changes are indicative of degenerative changes in the vertebral endplates and adjacent bone marrow, which contribute to chronic pain.
ICD-10 Diagnosis CodesHealthcare providers use specific ICD-10 diagnosis codes to document the medical necessity of the Intracept Procedure. These codes ensure that the procedure is correctly identified and justified when submitting claims to insurers. Key ICD-10 codes include:

• M47.816: Spondylosis without myelopathy or radiculopathy, lumbar region
• M47.817: Spondylosis without myelopathy or radiculopathy, lumbosacral region
• M51.36: Other intervertebral disc degeneration, lumbar region
• M51.37: Other intervertebral disc degeneration, lumbosacral region
• M54.50: Low back pain, unspecified
• M54.51: Vertebrogenic low back pain; low back pain vertebral endplate pain

Providers should verify coverage and the use of these codes with Medicare Administrative Contractors (MACs) and third-party payers.
Medicare Physician Coding, RVU, and Payment for Facility Settings:
​When billing Medicare for the Intracept Procedure performed in a facility setting, the following CPT codes and payment details are used:

• CPT 64628: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies, lumbar or sacral.
  • Work RVUs: 7.15
  • Total RVUs: 12.37
  • Medicare Payment Rate: $404.96 (subject to geographic adjustments)
• CPT +64629: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral.
  • Work RVUs: 3.77
  • Total RVUs: 5.85
  • Medicare Payment Rate: $191.51 (subject to geographic adjustments)

The total RVUs include work, practice expense, and malpractice components, multiplied by the conversion factor for the current year (e.g., $32.4772 for 2024).
Facility ReimbursementHospital Outpatient Departments (HOPD):

• CPT 64628:
  • Status Indicator: J1 (paid under comprehensive APC)
  • APC: 5115
  • Medicare Payment: Approximately $12,552 (national average)
• CPT +64629:
  • Status Indicator: N (bundled with the primary procedure)
  • APC: N/A
  • Medicare Payment: Bundled with the primary procedure
• HCPCS C1889: Implantable/insertable device, not otherwise classified. This code is necessary for reporting the device cost in hospital outpatient settings and must be reported with Revenue Code 278.

Ambulatory Surgical Centers (ASC):

• CPT 64628:
  • Status Indicator: J8 (device-intensive procedure)
  • APC: 5115
  • Medicare Payment: Approximately $9,396 (national average)
• CPT +64629:
  • Status Indicator: N (bundled)
  • APC: N/A
  • Medicare Payment: Bundled

Additional Considerations

• Global Period: CPT code 64628 has a global period of 10 days.
• Medically Unlikely Edits (MUE): Medicare has assigned an MUE for CPT code 64629, meaning claims for more than three units may be denied. However, appeals can be made if medically necessary.
• Device Reporting: For device-intensive procedures, HCPCS code C1889 is required to report the cost of the implantable device when no specific code exists. This must be reported with Revenue Code 278.

Proper documentation and accurate coding are crucial for ensuring the medical necessity and securing reimbursement for the Intracept Procedure. Providers should regularly consult the latest CMS guidelines and payer-specific requirements to ensure compliance and optimize reimbursement. For further assistance, healthcare providers can refer to Relievant Reimbursement Resources for comprehensive guidance on coding, coverage, and payment.

​Insurance Coverage for the Intracept Procedure and the Prior Authorization Process

Medicare Coverage:

• The Centers for Medicare & Medicaid Services (CMS) cover the Intracept Procedure under specific conditions outlined in local coverage determinations (LCDs) issued by Medicare Administrative Contractors (MACs). Providers must consult the applicable LCDs in their region to understand the coverage criteria and documentation requirements​ (Intracept by Relievant)​.

Private Insurance:

• Coverage policies for the Intracept Procedure vary among private insurers. Some insurers, such as Humana, have established positive coverage policies recognizing the clinical benefits of the procedure. However, it is essential to verify coverage with each insurer and follow their specific guidelines for pre-authorization and reimbursement​ (Intracept by Relievant)​.

Steps to Verify Insurance Coverage:

1. Check Payer Policies: Review the insurance company’s coverage policy for the Intracept Procedure. This can often be found on the payer’s website or by contacting their provider relations department.
2. Pre-Authorization Requirements: Determine if the insurance company requires pre-authorization and understand the documentation needed to support the request.
3. Submit Documentation: Provide all necessary clinical documentation, including patient history, MRI findings, and evidence of conservative treatment failure.

Prior Authorization ProcessPrior authorization is a crucial step to ensure that the Intracept Procedure is covered by the patient's insurance plan. The process involves several steps to demonstrate medical necessity and obtain approval from the insurance company.
Steps in the Prior Authorization Process:

1. Initial Request:
   • Submit a prior authorization request to the insurance company.
   • Include comprehensive clinical documentation, such as patient history, MRI results showing Modic changes, and evidence of conservative treatment failure.
2. Approval/Denial:
   • If approved, the insurance company will provide authorization for the procedure, and it can be scheduled.
   • If denied, the provider and patient have the option to appeal the decision.
3. Appeal Process:
   • Internal Appeal: Submit an appeal with additional documentation to support the medical necessity of the procedure.
   • External Appeal: If the internal appeal is denied, request an external review by an Independent Review Organization (IRO).

Relievant Medsystems offers a patient access program to assist patients and providers through the prior authorization and appeal processes. The program helps ensure that all necessary documentation is submitted, monitors the appeal process, and educates insurance companies on the clinical benefits of the Intracept Procedure​ (Intracept by Relievant)​.

​Reimbursement for the Intracept ProcedureHospital Outpatient Departments (HOPD):

• The procedure is reimbursed under Ambulatory Payment Classification (APC) 5115. Providers should verify the specific APC rates with the payers and ensure compliance with billing guidelines.

Documentation and ComplianceAccurate documentation is critical for successful billing and reimbursement of the Intracept Procedure. Providers must ensure that the documentation reflects the patient’s condition, the medical necessity of the procedure, and adherence to payer guidelines.
Key Documentation Components:

• Patient’s clinical history and symptoms.
• MRI findings showing Modic Type 1 or Type 2 changes.
• Documentation of conservative treatments tried and failed.
• Detailed procedure notes, including CPT and ICD-10 codes used.
• Correspondence with the insurance company regarding prior authorization and appeals.

7. Resources and SupportRelievant Medsystems provides a wealth of resources to assist healthcare providers with billing, coding, and reimbursement for the Intracept Procedure. These resources include detailed reimbursement guides, coding support, and patient access programs.
Key Resources:

• Reimbursement Guide: A comprehensive guide that outlines the coding, coverage, and payment information for the Intracept Procedure. The guide is updated annually to reflect any changes in reimbursement policies. Reimbursement Guide by Relievant.
• Patient Access Program: Assistance with prior authorization, appeals, and educating insurance companies about the clinical benefits of the procedure.
• Contact Information: For specific questions or support, contact Relievant’s reimbursement team at [email protected].

Navigating the billing, coding, insurance coverage, and prior authorization processes for the Intracept Procedure can be complex. However, with a thorough understanding of the CPT codes, ICD-10 diagnosis codes, payer policies, and documentation requirements, healthcare providers can ensure proper reimbursement and improve patient access to this innovative treatment for chronic low back pain. By leveraging the resources and support provided by Relievant Medsystems, providers can effectively manage these processes and provide their patients with the benefits of the Intracept Procedure.
For additional information and resources, visit the Relievant Medsystems website: Relievant Medsystems​

​Medicare Local Coverage Determination (LCD) for the Intracept Procedure

The Intracept Procedure, a minimally invasive treatment designed to alleviate chronic vertebrogenic low back pain, has specific Local Coverage Determinations (LCDs) issued by Medicare Administrative Contractors (MACs). These LCDs outline the conditions under which the procedure is considered medically necessary and thus covered by Medicare within the specific jurisdiction of each MAC.
Key LCDs and Coverage Information

1. Noridian Healthcare Solutions LCD (L39644)
   
   • Coverage: This LCD covers the Intracept Procedure for patients with chronic low back pain that has lasted for at least six months and has not responded to conservative treatments such as physical therapy or medications. The presence of Modic Type 1 or Type 2 changes on MRI is a critical criterion.
   • Process: The policy went through a standard review process, including a public comment period and revisions based on feedback before becoming active​ (Medicare)​​ (Intracept by Relievant)​.
2. Palmetto GBA LCD
   
   • Coverage Area: This MAC covers Medicare patients in Alabama, Georgia, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia.
   • Effective Date: The LCD became effective on March 5, 2023.
   • Criteria: Similar to Noridian's LCD, Palmetto GBA's coverage includes patients with MRI-confirmed Modic changes and those who have not responded to conservative care for at least six months​ (Intracept by Relievant)​.

Coverage CriteriaThe common criteria across these LCDs include:

• Duration of Pain: Chronic low back pain persisting for at least six months.
• Failed Conservative Treatment: Lack of significant improvement from conservative treatments over at least six months.
• MRI Findings: MRI evidence of Modic Type 1 or Type 2 changes, indicating inflammation or degeneration at the vertebral endplates.

Billing and Coding

• CPT Codes:
  • 64628: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies, lumbar or sacral.
  • +64629: Each additional vertebral body, lumbar or sacral.
• HCPCS Code:
  • C1889: Implantable/insertable device, not otherwise classified, used for reporting the device cost.

Reimbursement RatesReimbursement rates vary by setting and geographic location. For example:

• Hospital Outpatient Departments (HOPD): Approximately $12,552 (national average).
• Ambulatory Surgery Centers (ASC): Approximately $9,396 (national average).

These rates are subject to geographic adjustments and specific payer contracts.

Medicare Advantage Coverage for the Intracept Procedure

Medicare Advantage plans, which are offered by private insurance companies approved by Medicare, may provide coverage for the Intracept Procedure under certain conditions. Here’s a detailed overview of the coverage policies and what you need to know:
Key Coverage Policies

1. Humana:
   • Coverage Policy: Humana has published a favorable coverage policy for the Intracept Procedure as of November 2023. This policy expands access to the procedure for more than 13 million patients. The decision to cover the procedure is based on its proven efficacy for treating vertebrogenic pain, as supported by clinical evidence.
   • Requirements: The patient must have chronic low back pain for at least six months that has not responded to conservative treatments and have MRI evidence of Modic Type 1 or Type 2 changes.
2. Anthem Blue Cross Blue Shield:
   • Coverage Policy: Anthem Blue Cross Blue Shield established a favorable coverage policy for the Intracept Procedure in September 2023. This policy extends coverage to more than 36 million patients. The decision was influenced by the robust clinical evidence supporting the procedure’s effectiveness and safety.
   • Requirements: Similar to other policies, patients need to have chronic low back pain unresponsive to conservative treatments for at least six months, along with MRI-confirmed Modic changes.
3. Cigna Healthcare:
   • Coverage Policy: Cigna implemented a positive coverage policy in June 2023, making the Intracept Procedure available to over 19 million individuals. This decision is part of Cigna's broader effort to cover innovative treatments that provide substantial clinical benefits.
   • Requirements: Coverage criteria include chronic low back pain for a minimum of six months, failure to improve with conservative care, and MRI findings showing Modic changes.

General Coverage RequirementsFor Medicare Advantage plans to cover the Intracept Procedure, patients typically must meet the following criteria:

• Chronic Pain Duration: The patient has had chronic low back pain for at least six months.
• Conservative Treatment Failure: The patient has not experienced significant improvement despite undergoing at least six months of conservative treatments such as physical therapy, medications, or injections.
• MRI Evidence: There must be MRI findings showing Type 1 or Type 2 Modic changes, which indicate inflammation or degeneration at the vertebral endplates.

Procedure and Reimbursement Details

• Procedure Description: The Intracept Procedure involves using radiofrequency energy to ablate the basivertebral nerve, which helps in reducing pain by preventing the nerve from transmitting pain signals to the brain. It is performed as an outpatient procedure and typically takes about one hour.
• Reimbursement: The reimbursement rates for the Intracept Procedure can vary depending on the setting. For hospital outpatient departments, the average Medicare reimbursement is approximately $12,552, while for ambulatory surgery centers, it is around $9,396. These rates are subject to geographic adjustments and specific contractual agreements.

Further InformationFor more detailed information on the Intracept Procedure and specific coverage policies, you can refer to resources provided by Relievant Medsystems and the respective insurance providers. Here are some useful links:

• Relievant Medsystems
• Humana Coverage Policy
• Anthem Blue Cross Blue Shield Coverage Policy

These resources will provide comprehensive details on coverage criteria, reimbursement, and procedural guidelines.

Coverage for the Intracept Procedure under Workers' Compensation and Motor Vehicle Accident Injury Insurance

Workers' Compensation InsuranceWorkers' compensation insurance typically covers medical treatments and rehabilitation costs for injuries that occur on the job. The Intracept Procedure, used to treat chronic vertebrogenic low back pain, may be covered under workers' compensation insurance if the injury is work-related and meets specific criteria. Here’s what you need to know:

1. Eligibility Criteria:
   
   • Work-Related Injury: The patient must have sustained a work-related injury that leads to chronic low back pain.
   • Documentation: Detailed medical documentation is required to demonstrate that the chronic pain is a result of the workplace injury and that the patient has not responded to conservative treatments over at least six months.
2. Claims Process:
   
   • Prior Authorization: Often, prior authorization is needed before the procedure can be performed. This involves submitting medical records, including MRI results showing Modic changes, to the workers' compensation insurer.
   • Approval and Appeals: If the initial claim is denied, there is a process for appeals where additional documentation and justification for the procedure’s necessity can be provided.
3. Reimbursement:
   
   • Cost Coverage: Workers' compensation insurance typically covers the full cost of the procedure if approved, including any associated medical devices and follow-up care.

For more detailed information on workers' compensation benefits, you can refer to resources such as the Washington State Department of Labor & Industries workers' compensation guide​ (WA Labor & Industries)​​ (WA L&I)​.
Motor Vehicle Accident Injury InsuranceMotor vehicle accident (MVA) injury insurance, often part of personal injury protection (PIP) coverage, may also cover the Intracept Procedure if the chronic low back pain results from a car accident. Here’s how it works:

1. Eligibility Criteria:
   
   • Accident-Related Injury: The patient must have chronic low back pain directly resulting from a motor vehicle accident.
   • Conservative Treatment Failure: Similar to workers' compensation, the patient must have failed to respond to conservative treatments for at least six months.
2. Claims Process:
   
   • Documentation: Comprehensive medical documentation is required, including MRI findings, to support the claim that the pain is vertebrogenic and accident-related.
   • Coordination with Insurers: The claim is submitted to the auto insurer, which may require prior authorization and detailed documentation to approve the procedure.
3. Reimbursement:
   
   • Coverage: If approved, MVA injury insurance typically covers the procedure's costs, similar to workers' compensation insurance. This includes pre-procedure evaluations, the procedure itself, and follow-up care.

General Advice for Patients and Providers

• Consultation: It is crucial to consult with the insurance provider (workers' compensation or auto insurer) to understand the specific requirements and documentation needed for approval.
• Detailed Medical Records: Maintain thorough medical records, including evidence of failed conservative treatments and detailed MRI reports showing Modic changes.
• Appeals Process: Be prepared to navigate the appeals process if the initial claim is denied, providing additional documentation and justification as needed.

For further assistance and detailed guidelines, healthcare providers and patients can refer to resources from Relievant Medsystems, which offer support for insurance coverage and reimbursement for the Intracept Procedure. Visit Relievant Medsystems for more information.

TRICARE Policy Guidelines for the Intracept Procedure
Overview of CoverageTRICARE, the healthcare program for uniformed service members, retirees, and their families, provides specific coverage guidelines for radiofrequency denervation procedures, which include the Intracept Procedure. Here's a detailed explanation of the policy guidelines:
Eligibility Criteria for Coverage

1. Chronic Pain Duration:
   • The patient must have chronic low back pain that has persisted for at least six months.
2. Conservative Treatment Failure:
   • The patient must have tried and failed to achieve significant relief from at least three months of conservative management. This includes treatments such as:
     • Acetaminophen or nonsteroidal anti-inflammatory medications.
     • Physical therapy or home exercise programs.
     • Manipulation therapy.
3. Diagnostic Confirmation:
   • There must be documented evidence of Modic Type 1 or Type 2 changes on an MRI. These changes are indicative of vertebrogenic pain and justify the use of the Intracept Procedure.
4. Diagnostic Medial Branch Blocks:
   • A trial of controlled diagnostic medial branch blocks under fluoroscopic guidance must have resulted in at least a 50% reduction in pain, confirming the facet joint origin of the pain.
5. Exclusions:
   • The procedure is not covered for patients with prior spinal fusion surgery at the vertebral level being treated.
   • TRICARE does not cover pulsed radiofrequency ablation for spinal, back, or thoracic facet pain as it is considered unproven for these conditions.

Pre-Authorization and Documentation

• Prior Authorization: While not always required for beneficiaries (excluding active duty service members), obtaining a benefit review is recommended to ensure coverage.
• Letter of Attestation: Providers can expedite the review process by attaching a letter of attestation in lieu of extensive clinical documentation when submitting the request.

Appeals ProcessIf the initial request for coverage is denied, patients and providers can appeal the decision by providing additional documentation that supports the medical necessity of the procedure. This may include more detailed MRI reports, patient history, and evidence of failed conservative treatments.
Contact InformationFor more details on the policy and to ensure compliance with specific requirements, providers and patients can refer to the TRICARE West region provider page on radiofrequency denervation or contact TRICARE directly:

• TRICARE West RF Denervation

Citations and References:
​Key Resources and Contact InformationFor comprehensive guidance, including downloadable forms and additional support, physicians and facilities can refer to the reimbursement guide provided by Relievant Medsystems. The guide is updated annually to reflect any changes in reimbursement policies.

• Reimbursement Guide: Reimbursement Guide by Relievant
• Contact Relievant: For specific questions or support, contact Relievant’s reimbursement team at [email protected].

By following these guidelines and leveraging available resources, healthcare providers can effectively manage the billing, coding, and reimbursement processes for the Intracept Procedure, ensuring that patients receive the benefits of this innovative treatment for chronic low back pain.

Take-aways:
​GoHealthcare Practice Solutions for Prior Authorization AssistanceNavigating the complexities of prior authorization for procedures like the Intracept Procedure can be challenging. GoHealthcare Practice Solutions offers comprehensive support to streamline this process and ensure successful approval and reimbursement.
Services Provided:

• Prior Authorization: Assistance with obtaining prior authorizations, including preparation and submission of necessary documentation.
• Appeals Support: Help with the appeals process if initial requests are denied, including additional documentation and justification.
• Insurance Coordination: Coordination with TRICARE and other insurers to confirm coverage and verify appropriate coding.
• Documentation: Ensuring that all medical records and supporting documents are thorough and meet insurer requirements.

Contact GoHealthcare Practice Solutions: For more information and support with prior authorization and other healthcare management needs, visit GoHealthcare Practice Solutions or contact their team directly.
By leveraging the expertise of GoHealthcare Practice Solutions, healthcare providers can navigate the prior authorization process more efficiently, ensuring patients receive the necessary care without undue delays.