CMS Pub. 100-04, ch. 32, § 330.2

Hospital Outpatient facilities shall bill for percutaneous image-guided lumbar decompression (PILD) procedure code

0275T end date 12/31/25 effective on or after January 9, 2014 (note 0275T is being replaced with 62330 effective

01/01/26), or procedure code G0276 effective on or after January 1, 2015, for lumbar spinal stenosis (LSS) on a 13X or

85X TOB. Refer to Section 69 of this chapter for further guidance on billing under CED.

Effective for dates of service on or after December 7, 2016, Medicare will cover PILD under CED for beneficiaries with

LSS who are enrolled in a CMS -approved prospective longitudinal study for PILD procedures using a FDA -

approved/cleared device that completed a CMS-approved randomized, controlled clinical trial (RCT) that met the criteria

listed in the January 2014 NCD (see CR 8757, transmittal # 2959, dated May 16, 2014).

Hospital outpatient procedures for PILD shall be covered when billed with:

• ICD-9 V70.7 (ICD-10 Z00.6) and Condition Code 30.

• Modifier Q0

• An 8-digit clinical trial identifier number listed on the CMS Coverage with Evidence Development website

Hospital outpatient procedures for PILD shall be rejected when billed without:

• ICD-9 V70.7 (ICD-10 Z00.6) and Condition Code 30.

• Modifier Q0

• An 8-digit clinical trial identifier number listed on the CMS Coverage with Evidence Development website

Claims billed by hospitals not participating in the trial /registry, shall be rejected with the following message:

CARC: 50 -These are non-covered services because this is not deemed a “medical necessity” by the payer.

RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage

determination as to whether a particular item or service is covered. A copy of this policy is available at

http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a

copy of the NCD.

Group Code –Contractual Obligation (CO)

MSN 16.77 – This service/item was not covered because it was not provided as part of a qualifying trial/study. (Este

servicio/artículo no fue cubierto porque no estaba incluido como parte de un ensayo clínico/estudio calificado.)