Functional Electrical Stimulation (FES) - Coverage and HCPCS Coding - Revised - JD DME

Joint DME MAC Publication

In April 2003 the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) establishing coverage for functional electrical stimulation (FES) to enable spinal cord injured (SCI) patients to walk (see National Coverage Determinations Manual 100-3 Chapter 1, Part 2, Section 160.12).

Functional electrical stimulation is a technique that uses electrical impulses to activate paralyzed or weak muscles in precise sequence. The FES device transmits these electrical impulses via surface electrodes in the same manner as neuromuscular electrical stimulation (NMES). For example, through selective and sequential stimulation of various lower extremity muscle groups, FES can enable spinal cord injured (SCI) patients to walk.

Coverage of NMES (other than FES) to treat muscle atrophy is limited to the treatment of patients with disuse atrophy where the nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves and other non-neurological reasons for disuse atrophy. There has been no change in coverage criteria when NMES is used to treat disuse atrophy.

Coverage of FES

Medicare will consider coverage of FES for SCI patients who have completed a training program consisting of at least 32 physical therapy sessions with the device, over a period of three months.

Per the CMS NCD 160.12, coverage for FES to enhance walking will be limited to SCI patients with ICD-10 codes G04.1 –Tropical spastic paraplegia, G82.21 - Paraplegia, complete, G82.22 - Paraplegia, incomplete, and with all of the following characteristics:

1. Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve); and,
2. Persons with muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently; and,
3. Persons that demonstrate brisk muscle contraction to NMES and have sensory perception of electrical stimulation sufficient for muscle contraction; and,
4. Persons that possess high motivation, commitment and cognitive ability to use such devices for walking; and,
5. Persons that can transfer independently and can demonstrate standing independently for at least three minutes; and,
6. Persons that can demonstrate hand and finger function to manipulate controls; and,
7. Persons with at least six-month post recovery spinal cord injury and restorative surgery; and,
8. Persons without hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and,
9. Persons who have demonstrated a willingness to use the device long-term.

FES used to enhance walking for SCI patients with any of the following conditions, will not be covered:

1. Presence of cardiac pacemakers;
2. Severe scoliosis or severe osteoporosis;
3. Irreversible contracture;
4. Autonomic dysreflexia; or
5. Skin disease or cancer at area of stimulation

Indications for FES other than to enable SCI patients to walk will be denied as not medically necessary.

The only settings where therapists with the sufficient skills to provide these services are employed are inpatient hospitals, outpatient hospitals, comprehensive outpatient rehabilitation facilities and outpatient rehabilitation facilities. The physical therapy necessary to perform this training must be part of a one-on-one training program.

HCPCS Coding

Two codes are used to bill for FES:

• E0764 - FUNCTIONAL NEUROMUSCULAR STIMULATION, TRANSCUTANEOUS STIMULATION OF SEQUENTIAL MUSCLE GROUPS OF AMBULATION WITH COMPUTER CONTROL, USED FOR WALKING BY SPINAL CORD INJURED, ENTIRE SYSTEM, AFTER COMPLETION OF TRAINING PROGRAM
• E0770 - FUNCTIONAL ELECTRICAL STIMULATOR, TRANSCUTANEOUS STIMULATION OF NERVE AND/OR MUSCLE GROUPS, ANY TYPE, COMPLETE SYSTEM, NOT OTHERWISE SPECIFIED

Note that HCPCS codes E0764 and E0770 represent the "entire system" for the FES devices. Therefore, individual components such as walkers, crutches or other supplies must not be billed separately.

Manufacturers of products billed with code E0770 must have the code(s) verified by the Pricing, Data Analysis, and Coding (PDAC). Currently, the only products that are coded E0770 are:

• WalkAide (Innovative Neurotronics)
• Odstock DROP FOOT STIMULATOR PACE (Odstock Medical/Boston Brace)
• NESS L300 and H200 devices (Bioness)
• Deluxe Digital Electronic Muscle Stimulator (Drive medical)

Code E0764 does not require code verification by the PDAC; however, currently the only product that is coded E0764 is the Parastep I (Sigmedics).

For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 or e-mail the PDAC by completing the DME PDAC Contact form located on the PDAC website here.

Please refer to the Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) for additional coding and documentation requirements.

Revision History