Coding for Physicians

Favorable coverage for Vagus Nerve Stimulation using the VNS Therapy™ System has been recommended and/or adopted by most payers across the United States. If a particular payer is not already covering VNS Therapy, the Cyberonics Reimbursement Team can provide information and help you obtain adequate coverage for your patients.

Medicare
Effective July 1, 1999, CMS (formerly the Healthcare Financing Administration - HCFA) issued a National Coverage Policy Transmittal 114 (Section 60-22). The coverage policy states that vagus nerve stimulation for the treatment of seizures is a safe and effective treatment for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. This policy is in accordance with the FDA-labeled usage for the device.

Inpatient Reimbursement: When the VNS Therapy System is provided as an inpatient service for patients covered by Medicare, payment for all of the services during the hospital admission, including the VNS Therapy System, will be included in an all-inclusive prospective amount known as the Diagnosis Related Group (DRG) payment.

Outpatient Reimbursement: Medicare’s Ambulatory Payment Classification (APC) prospective payment system for hospital outpatient services took effect on August 1, 2000. APCs are to hospital outpatient care what DRGs are to inpatient care. APCs include essentially all except those covered by a separate fee schedule or payment system. Hospital payment amounts will be based on hospital charges adjusted to cost by cost-to-charge ratio (RCC). Medicare will provide this ratio.

Medicaid
Medicaid programs cover hospital inpatient and outpatient services that are medically necessary and appropriate. Most state Medicaid agencies have developed their own coverage policy for VNS Therapy or adopted the National CMS coverage policy. In some cases, prior authorization is required. Reimbursement mechanisms vary state by state. Contact your state Medicaid agency for specific reimbursement information.

Private Payers
Private payers also cover hospital inpatient and outpatient services that are considered to be medically necessary. As with other payers, many private payers have developed clinical guidelines for coverage or adopted the National CMS coverage policy for use of the VNS Therapy System. In some cases written prior authorization is required. Reimbursement mechanisms will vary from plan to plan. Contact your specific payer for additional information.

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