Coding for Inspire

Question:

How do we go about coding the new Inspire V that has only a stimulation lead and no sensing lead? Also, how would we code a revision from Inspire IV to Inspire V?

Answer:

The new Inspire V system received FDA approval on August 2, 2024 and is coded using CPT 64568, which describes the open implantation of a cranial nerve neurostimulator and pulse generator. This is appropriate because Inspire V includes only a stimulation lead, unlike Inspire IV, which includes both a stimulation and a sensing lead and is coded as 64582.

For revisions from Inspire IV to Inspire V, the correct code is CPT 61885. This code is used for the replacement of a cranial neurostimulator pulse generator with connection to a single electrode array, which accurately reflects the Inspire V configuration. Other revision codes assume the same device architecture and are not appropriate when transitioning from a dual-lead to a single-lead system. Coders can identify the use of Inspire V in the operative note by the absence of a sensing lead, and by the fact that the procedure does not require dissection through the pectoralis muscle both of which you may see involved in an Inspire IV operative note. 

From a reimbursement perspective:

• Medicare has revised NCD 160.18 to allow ICD-10 code G47.33 (Obstructive Sleep Apnea) to be billed with CPT 64568. This change was implemented on July 1, 2025, but is retroactively effective to January 1, 2025. Additionally secondary diagnosis requirement of BMI are still required to support medical necessity.

• While many commercial payers have adopted this coding alignment, some have not, so it is essential to verify coverage and coding acceptance with each payer individually.

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 13939, documented in:

• MM13939 – ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2025 Update (PDF)

• R13097OTN – CMS Manual System Transmittal

*This response is based on the best information available as of 8/14/25.

Incident-to Billing for Medicare

Question:

We bill incident-to for Medicare patients in our office for our physician assistants. We don’t have a Otolaryngologist in the office on Friday afternoons but our 5 PAs are in seeing patients. Can we bill their services “incident to” the physician they work for?

Answer:

You are not able to bill the service Incident-to when a physician is not in the office suite. A supervising physician must be on-site providing supervision in order to bill “incident to.” In your case, you will bill direct using the PA’s name and NPI (national provider identification) number.

*This response is based on the best information available as of 7/31/25.

Claim Denial with Modifiers 24/58

Question:

I have been getting denied for office visits (99212-99215) billed during a global period. I bill the E/M code with a modifier 24, and/or 58 and the claims still get denied for “separately billed services/tests as they are considered components of the procedure. Separate payment is not allowed.” According to the conferences I have attended for KZA, we’ve been told that we can bill and E/M code with modifier 24, but the insurances do not cover it. Do you have any other suggestions on how to get these claims paid?

Answer:

Thank you for your question. Billing an E/M service during a global period can be tricky, especially when insurers bundle them into the procedure. Here are some strategies to improve claim approvals:

1. Ensure Documentation Supports the Modifier

• Modifier 24: Must show that the E/M service is unrelated to the procedure. If the visit is for post-op care, insurers will likely deny it.

• Modifier 58: Used for staged or related procedures, not routine post-op visits or visits unrelated to the procedure.

2. Check Payor-Specific Guidelines

• Medicare and private payors may interpret what qualifies as an unrelated E/M service differently.

• Some payors require additional documentation proving medical necessity.

3. Use Diagnosis Codes That Support Unrelated Services

• If the diagnosis code is too closely related to the procedure, payors may still bundle the visit.

• Consider adding supporting notes explaining why the visit was medically necessary.

4. Appeal Denied Claims

• If you believe the denial was incorrect, submit an appeal with detailed documentation.

• Include payor guidelines that support separate reimbursement.

*This response is based on the best information available as of 7/17/25.

Evaluation and Management Service on the Same Date as an Office Procedure

Question:

A patient came into the office for a balloon sinus ostia catheterization and dilation of the maxillary, sphenoid and frontal sinuses bilaterally. My surgery scheduler has already obtained pre-certification for the procedure as it is covered in the office setting. I performed an examination and then did the procedure. I then performed a sphenoid, frontal, and maxillary dilation bilaterally. Can I bill an E/M service since I examined the patient?

Answer:

No, since the focus of the visit was the procedure and you have already obtained precertification for the procedures on the sphenoid and frontal sinus dilation (CPT 31298-50) and the maxillary dilation (31295-50), the E/M service is inherent to the procedure and should not be reported separately.  In this situation there is not a significant separate identifiable justification for an E/M service.

*This response is based on the best information available as of 7/03/25.

Ablation of Thyroid Nodules

Question:

My physician performed a percutaneous radiofrequency ablation of 3 thyroid nodules, one in the lower part of the left lobe and 2 in the right lobe. I am not sure what CPT code I should report. Can you help?

Answer:

Certainly. There are 2 new CPT codes to report percutaneous radiofrequency ablation of thyroid nodules: CPT code 60660 (Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, including imaging guidance, radiofrequency) and CPT code 60661, an add-on code for the additional lobe. In this instance, you will report 60660 for the left lobe and 60661 for the right lobe. Keep in mind that imaging guidance is included and should not be reported separately.

*This response is based on the best information available as of 6/19/25.

Myringoplasty using a Water-insoluble, Off-white, Nonelastic, Porous, and Pliable Product

Question:

If a physician performs a myringoplasty and uses a water-insoluble, off-white, nonelastic, porous, and pliable product, would it be appropriate to report code 69620 alone or 69620 appended with modifier 52, Reduced Services?

Answer:

No, if the preparation of the perforation edges and a water-insoluble, off-white, nonelastic, porous, pliable product was used as a patch to the drum defect, code 69610, Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch, would be reported. If a tissue graft was harvested and edges prepared for the drum defect repair, then code 69620, Myringoplasty (surgery confined to drumhead and donor area), would be reported.

*This response is based on the best information available as of 6/05/25.