Notification

Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies


Notification Issue Date: 04/04/2018

This version of the policy will become effective 05/07/2018.

  • The following ICD-10 CM codes have been added to this policy, in Attachment A, as indications that are considered experimental/investigational when billed with HCPCS codes E0720 and E0730:
    M26.621 Arthralgia of right temporomandibular joint
    M26.622 Arthralgia of left temporomandibular joint
    M26.623 Arthralgia of bilateral temporomandibular joint
    M26.629 Arthralgia of temporomandibular joint, unspecified side
    R10.10 Upper abdominal pain, unspecified visceral abdominal pain -
    R10.11 Right upper quadrant pain
    R10.12 Left upper quadrant pain
    R10.13 Epigastric pain
    R10.2 Pelvic and perineal pain
    R10.30 Lower abdominal pain, unspecified
    R10.31 Right lower quadrant pain
    R10.32 Left lower quadrant pain
    R10.33 Periumbilical pain



Medical Policy Bulletin


Title:Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies

Policy #:05.00.74c



The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATORS (TENS) (E0720, E0730)
Acute post-operative pain
A TENS and related supplies are considered medically necessary and, therefore, covered for the treatment of acute post-operative pain
  • Coverage is provided for 30 days from the day of surgery. Reimbursement will only be made as a rental.

Chronic Pain
For the treatment of chronic pain (present for at least 3 months), a 30-60 day trial TENS is considered medically necessary and, therefore, covered when both of the criteria are met:
  • The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy
  • The individual has tried and failed other appropriate treatment modality's (e.g., physical therapy, pharmacotherapy)

Continued coverage after the trial of a TENS for the treatment of other types of chronic pain is considered medically necessary and, therefore, covered when the effectiveness in modulating pain with the device has been monitored by the professional provider and documented in the individual's medical record and both of the following have been demonstrated:
  • Reduction in pain of 50 percent or more since the start of the trial period of a TENS
  • There is objective evidence of pain relief (e.g., decreased opioid usage, improved range of motion of the affected area, increased activity, increased pain relief according to the Visual Analog Scale [VAS] or the Numeric Pain Intensity Scale).

During the 30-60 day trial period, reimbursement for the TENS device will only be made as a rental. If the trial of the device is successful in modulating pain and the individual continues using the device, the rental cost of the device is included in the purchase price of the TENS device.

If the continued coverage criteria after the trial of a TENS device is not met, such that the trial period was not successful, reimbursement will not be made beyond the 30-60 day rental period.

The professional provider ordering the TENS and related supplies must be the treating professional provider for the disease or condition justifying the need for the TENS.

SUPPLIES
Replacement supplies are considered medically necessary and, therefore, covered when used with a medically necessary TENS. The usual maximum utilization for supplies are:
  • 2 lead TENS - a maximum of one unit of A4595 per month (12 per year)
  • 4 lead TENS - a maximum of two units of A4595 per month (24 per year)
  • Replacement of lead wires (A4557) - once every 12 months

A TENS supply allowance (A4595) includes electrodes (any type) (A4556), conductive paste or gel (if needed, depending on the type of electrode) (A4558), tape or other adhesive (if needed, depending on the type of electrode), adhesive remover, skin preparation materials, batteries (9 volt or AA, single use or rechargeable) (A4630) and a battery charger (if rechargeable batteries are used). Therefore, these items will not be eligible for separate reimbursement if reported on the same date of service or within 30 days of A4595.

Rental

During the rental of a TENS (E0720, E0730), supplies for the device are included in the rental reimbursement; there is no additional allowance for supplies (e.g., electrodes, lead wires, batteries).

Purchase

At the time of a TENS (E0720 or E0730) purchase following a successful trial period, the reimbursement for the TENS includes reimbursement for lead wires and 1 month’s supply of electrodes, conductive paste or gel (if needed), and batteries.

CONDUCTIVE GARMENT
A conductive garment used with a TENS (E0731) is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The garment is approved for marketing by the Food and Drug Administration (FDA)
  • It has been prescribed by the treating professional provider for use in delivering covered TENS treatment
  • The individual meets one of the following indications:
    • The individual cannot manage without the conductive garment because:
      • There is such a large area or so many sites to be stimulated, and
      • The stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes, and lead wires
    • The individual cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes, and lead wires
    • The individual has a documented medical condition, such as skin problems, that preclude the application of conventional electrodes, adhesive tapes, and lead wires
    • The individual requires electrical stimulation beneath a cast to treat chronic intractable pain.

A conductive garment used with a TENS (E0731) for chronic pain during the trial period is considered medically necessary and, therefore, covered when both of the following criteria are met:
  • The individual has a documented skin problem prior to the start of the trial period.
  • The TENS is considered medically necessary and, therefore, covered.

If the criteria above is not met for the conductive garment (E0731), it will be considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.

EXPERIMENTAL/INVESTIGATIONAL

A TENS device is considered experimental/investigational and, therefore, not covered for the treatment of chronic pain (present for at least 3 months) when the presumed etiology of the pain is a type that is not accepted as responding to TENS therapy because the safety and/or effectiveness of this device cannot be established by review of the available published peer-reviewed literature, including the following:
  • Visceral abdominal pain
  • Pelvic pain
  • Temporomandibular joint (TMJ) pain
  • Headache disorder pain (i.e., migraine; tension type headache; cluster headache and other trigeminal autonomic cephalgia; other primary headaches)
  • Low back pain that is not a manifestation of a clearly defined and generally recognizable primary disease entity

FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:
  • The treating professional provider must have an in-person examination with the individual
    within the six months prior to the date of the written order prior to delivery.
  • This examination must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.

A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified items are:
E0720 Transcutaneous electrical nerve stimulation (TENS) device, 2 lead, localized stimulation
E0730Transcutaneous electrical nerve stimulation (TENS) device, 4 or more leads, for multiple nerve stimulation
E0731 Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)

REQUIRED DOCUMENTATION

Transcutaneous electrical nerve stimulator (TENS) device for the treatment of individuals who have chronic pain, other than lower back pain, the medical record documentation must include the following:
  • The location of the pain
  • The severity of the pain
  • The duration of time the individual has had the pain
  • The presumed etiology of the pain
  • Prior treatment and results of that treatment
  • Re-evaluation of the individual at the end of the trial period, must include the following:
    • How often the individual used the TENS device
    • The typical duration of each time
    • The effectiveness of the TENS therapy

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

Documentation of a face to face encounter, between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s) must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

A 4-lead transcutaneous electrical nerve stimulator (TENS) may be used with either 2 leads or 4 leads, depending on the characteristics of the individual's pain. If it is ordered for use with 4 leads, the medical record must document why 2 leads are insufficient to meet the individual’s needs.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, TENS is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Description

A transcutaneous electrical nerve stimulator (TENS) is a nonpharmacologic and noninvasive treatment for symptomatic pain relief. A TENS is a battery-operated device that utilizes electrical current delivered through electrodes placed on the surface of the individual's skin to decrease the individual's perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins. Individuals do not feel pain until a coded message travels from the affected area along small nerve fibers leading into the spinal cord. Here the message is relayed to different nerves that travel up the spinal cord to the brain. There are several theories that have been hypothesized to support the clinical use of a TENS for pain relief. Originally, the Melzack and Wall's gate theory of pain was considered as the foundation of the mechanism of action for a TENS. In this theory, a “gate” in the dorsal horn of the spinal cord has the capacity to inhibit transmission of nociceptive stimulation to the ascending tracts of the nervous system. By using a TENS to activate the large-diameter afferent nerves of the peripheral nervous system, it was believed that these devices could block the painful sensations that were being felt by the individual. However, as more research has accumulated, investigators now believe that a TENS may produce pain relief by activating the supraspinal nervous system, as well as the afferent nerves that affect the spine. These effects are proposed to occur, at least in part, due to the modulation of the body’s endogenous chemicals (e.g., endorphins, glutamate) that affect the perception of pain (DeSantana 2008, Sluka 2009). Some also report that the use of a TENS causes a local dilatation of blood vessels in injured tissues (Noble 2000), which might mitigate nociceptive sensations.

In clinical practice, the electrical characteristics of a TENS are varied among the devices used and the clinicians who apply them. They can be applied with varying frequencies, from low (<10 hertz [Hz]) to high (>50 Hz). A TENS is usually perceived by an individual as a tingling sensation. High intensity usually involves motor contraction. A TENS can also be configured to deliver different types of output patterns for individuals, including those that produce constant pulses, and those that provide repetitive trains or bursts of electrical pulses delivered in a limited time period, followed by a specified period of no current flow. Moreover, a TENS may also be configured to produce a modulated output, so that one or several of the parameters of the electrical stimulation are cyclically changed during a single application of treatment.

Because the TENS was marketed prior to the 1976 Medical Device Amendments to the Federal Food, Drug, and Cosmetic Act, its market approval was “grandfathered” rather than the result of satisfying the requirements of the premarket approval (PMA) regime. TENS for pain relief is usually cleared under 510(k).

ACUTE POST-OPERATIVE PAIN AND CHRONIC PAIN

TENS has been widely used in the treatment of various types of pain, including acute post-operative pain and chronic pain. It has been shown that TENS is effective in relieving acute post-operative pain and reducing analgesic medications following surgical procedures. Evidence from prospective, randomized controlled studies supports the benefits of TENS for postoperative pain. DeSantana et al (2008) tested the hypoalgesic effect of high-frequency TENS (100 Hz) applied using a strong but comfortable sensory intensity used for 30 minutes 2 and 4 hours after unilateral inguinal herniorrhaphy. TENS significantly decreased analgesic requirements and incisional pain intensity for 24 hours postoperatively when compared with placebo. In another study, Cipriano et al (2008) tested a 4-hour high-frequency TENS treatment (80 Hz) with a strong but comfortable sensory intensity on 3 postoperative days following cardiac surgery and found significant decreases in incisional pain both at rest and with cough when compared with placebo TENS. This decrease in pain intensity was related to positive effects on pulmonary function, with significant increases in tidal volume, vital capacity, and electrical activity of the trapezius and pectoralis major muscles in individuals receiving active TENS but not sham TENS. Moreover, the use of TENS is also beneficial in the management of chronic pain. Meta-analyses for osteoarthritic knee pain has been supportive, suggesting that TENS is superior to sham for pain and stiffness (Bjordal 2007).

Evidence continues to emerge from both basic science and clinical trials that may support the use of TENS for the treatment of a variety of painful conditions while identifying strategies to increase TENS effectiveness (DeSantana 2008).

HEADACHE DISORDERS

According to the International Headache Society headache is defined as pain located above the orbitomeatal line. The International Headache Classification (ICHD II) classifies all headache disorders into major groups. Primary headache disorders include migraine; tension-type headache; cluster headache and other trigeminal autonomic cephalgia; and other primary headaches such as primary stabbing headache, primary cough headache, etc. Chronic primary headaches are described as attacks of headache that occur on more days than not over a period of longer than 3 months; except for trigeminal autonomic cephalgia, chronic status is not designated until the disorder has been unremitting for more than 1 year.

As noted, migraine is classified in the ICHD II as a primary headache disorder. Migraine is a chronic condition with recurrent episodic attacks. On March 11, 2014, The US Food and Drug Administration (FDA) approved the first TENS (i.e., Cefaly; Herstal, Belgium) through the de novo process for prophylactic treatment of episodic migraine in individuals 18 years of age or older based on a double-blinded, randomized, sham-controlled trial (Schoenen 2013). This study evaluated the safety and effectiveness of trigeminal neurostimulation with a supraorbital transcutaneous stimulator with the intent-to-treat in 67 individuals over a 3-month treatment period. The authors concluded that supraorbital transcutaneous stimulation with the device used in this trial is effective and safe as a preventive therapy for migraine. Limitations of this small study include the possibility of partial unblinding in this trial, and individuals in the treatment group were on average younger than those in the sham group with somewhat shorter duration of their migraine. In addition, it is unclear whether supraorbital transcutaneous stimulation is effective in individuals with more frequent migraine attacks or with chronic migraines. Furthermore, scientific evidence in the form of large, randomized, controlled trials using TENS for the treatment of headache disorders is lacking.

CHRONIC LOW BACK PAIN

Chronic low back pain has been defined as an episode of low back pain that has persisted for 3 months or longer, and it is not a manifestation of a clearly defined and generally recognizable primary disease entity. At this time, the evidence from the small number of placebo-controlled trials does not support the use of a TENS in the routine management of chronic low back pain. Further research is required to provide evidence of the clinical efficacy of TENS for chronic low back pain.

In 2009, guidelines from the American Academy of Neurology (AAN) published in an online version of Neurology in 2009, stated that transcutaneous electric nerve stimulation (TENS) is not effective for the treatment of chronic low back pain. This recommendation was a level A+, due to lack of proven efficacy.

OTHER ELECTRICAL STIMULATORS

A TENS must be distinguished from a neuromuscular stimulator, which is used to directly stimulate muscles and/or motor nerves, and from percutaneous electrical nerve stimulation (PENS), a minimally invasive stimulator, in which needle-like electrodes are temporarily inserted (to a depth of 1 to 4 centimeters) into the deep tissues (muscles, ligaments, tendons) around or immediately adjacent to the nerve serving the painful area in order to electrically stimulate the peripheral nerve fibers.


References


AAN Summary of Evidence-based Guideline for Clinicians Efficacy of ranscutaneous Electric nerve Stimulation in the Treatment of Pain in Neurologic Disorders. 2009. Available at:
https://www.aan.com/Guidelines/home/GetGuidelineContent/383. Accessed February 26, 2018.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. Detailed written orders and face-to-face encounters. [CMS Web site]. 07/01/2013 (Revised 03/14/2014). Available at:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworFebruary 26, 2018. k-MLN/MLNMattersArticles/downloads/MM8304.pdf. Accessed Jan. 12, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).10.2: Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain . 8/7/95.[ CMS Website]. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=145&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Pennsylvania&KeyWord=tens&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAAAA%3d%3d&. Accessed February 26, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 160.27: Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP) . Effective Date:6/8/2012. Implementation: 1/7/2013. [CMS Website].Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=354&ncdver=1&bc=AAAAQAAAAAAA&. Accessed February 26, 2018.

Centers for Medicare & Medicaid Services (CMS). Transcutaneous electrical nerve stimulation for chronic low back pain (CAG-00429N).Decision memo. [CMS Web site]. 06/08/12. Available at: http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=256. Accessed February 26, 2018.

DeSantana J, Sluka K. Central mechanisms in the maintenance of chronic widespread noninflammatory muscle pain. Current Pain and Headache Reports. 2008(a);12:338-343.

DeSantana J, Walsh D, Vance C, Rakel B, Sluka K. Effectiveness of transcutaneous electrical nerve stimulation for treatment of hyperalgesia and pain. Current Rheumatology Reports. 2008;10:492-499.

Dubinsky RM, Miyasaki J. Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology.2010;74(2):173-176.

Holland S, Silberstein SD, Freitag F, et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78(17):1346-1353.

International Headache Society. (2004). 2nd Edition of the International Headache Classification (ICHD-2): THE PRIMARY HEADACHES. Available at:http://ihs-classification.org/en/02_klassifikation/02_teil1/. Accessed February 26, 2018.

Khadilkar A, Odebiyi DO, Brosseau L. et al. Transcustneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Summaries. 05/31/2013. Available at:http://summaries.cochrane.org/CD003008/transcutaneous-electrical-nerve-stimulation-tens-versus-placebo-for-chronic-low-back-pain. Accessed February 26, 2018.

Magis D, Sava S, d’Elia TS, et al. "Safety and patients’ satisfaction of transcutaneous supraorbital neurostimulation (tSNS) with the Cefaly device in headache treatment: A survey of 2,313 headache sufferers in the general population." J Headache Pain. 2013;14:95.

Noridian Health Care Solutions, LLC. Local Coverage Article: Transcutaneous Electrical Nerve Stimulators (TENS) - Policy Article (A52520). Effective 1/1/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Transcutaneous+Electrical+Nerve+Stimulators+%28TENS%29%20LCD+and+PA/52e57b3b-fec4-4078-bcea-4ad556d06cef. Accessed February 26, 2018.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD) Transcutaneous Electrical Nerve Stimulators (TENS), L33802. Effective 10/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Transcutaneous+Electrical+Nerve+Stimulators+%28TENS%29%20LCD+and+PA/52e57b3b-fec4-4078-bcea-4ad556d06cef,. Accessed February 26, 2018.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. TENS device. AMD 6605. Premarket approval letter. [FDA web site]. 10/23/09. Available at:
http://www.accessdata.fda.gov/cdrh_docs/pdf9/K092990.pdf. Accessed February 26, 2018.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. TENS device. AMED StimPad™ Transcutaneous Electrical Nerve Stimulation (TENS) System. Premarket approval letter. [FDA Web site]. 03/13/08. Available at:http://www.accessdata.fda.gov/cdrh_docs/pdf7/K071120.pdf. Accessed
February 26, 2018.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Transcutaneous Electrical Nerve Stimulator (T.E.N.S.). EasyMed TN-28C TENS UNIT. Premarket approval letter. [FDA Web site]. 04/08/04.. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf4/k040253.pdf. Accessed
February 26, 2018.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Transcutaneous Electrical Nerve Stimulator to treat headache. Premarket approval letter. [FDA Web site]. 03/11/14. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf12/K122566.pdf. Accessed
February 26, 2018.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

MEDICALLY NECESSARY


G89.12 Acute post-thoracotomy pain

G89.18 Other acute postprocedural pain

G89.21 Chronic pain due to trauma

G89.29 Other chronic pain

G89.3 Neoplasm related pain (acute) (chronic)

G89.4 Chronic pain syndrome

Please refer to Attachment A for a list of ICD-codes considered Experimental/Investigational for the use of TENS.



HCPCS Level II Code Number(s)



THE FOLLOWING CODES REPRESENT TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICES:

E0720 Transcutaneous electrical nerve stimulation (TENS) device, 2 lead, localized stimulation

E0730 Transcutaneous electrical nerve stimulation (TENS) device, 4 or more leads, for multiple nerve stimulation

THE FOLLOWING CODES REPRESENT SUPPLIES USED WITH TENS DEVICES:

A4556 Electrodes (e.g., apnea monitor), per pair

A4557 Lead wires (e.g., apnea monitor), per pair

A4558 Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz

A4595 Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES)

A4630 Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient

E0731 Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)



Revenue Code Number(s)

N/A



Coding and Billing Requirements


Cross References

Attachment A: Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
Description: ICD 10 Codes




Policy History

REVISIONS FROM 05.00.74c
05/07/2018The following ICD-10 CM codes have been added to this policy, in Attachment A, as indications that are considered experimental/investigational when billed with HCPCS codes E0720 and E0730:
    M26.621 Arthralgia of right temporomandibular joint
    M26.622 Arthralgia of left temporomandibular joint
    M26.623 Arthralgia of bilateral temporomandibular joint
    M26.629 Arthralgia of temporomandibular joint, unspecified side
    R10.10 Upper abdominal pain, unspecified visceral abdominal pain -
    R10.11 Right upper quadrant pain
    R10.12 Left upper quadrant pain
    R10.13 Epigastric pain
    R10.2 Pelvic and perineal pain
    R10.30 Lower abdominal pain, unspecified
    R10.31 Right lower quadrant pain
    R10.32 Left lower quadrant pain
    R10.33 Periumbilical pain

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 05/07/2018
Version Issued Date: 05/07/2018
Version Reissued Date: N/A



2017 AmeriHealth.