Coverage and Authorization Services is available to respond to your coding questions toll-free at 800-292-2903.

For Urinary Control Commonly Billed Codes October 2010 Medtronic provides this information for your convenience only. It is not intended as a recommendation regarding clinical practice. It is the responsibility of the provider to determine coverage and to submit appropriate codes, modifiers, and charges for the services that were rendered. This document provides assistance for FDA approved or cleared indications. Where reimbursement is requested for a use of a product that may be inconsistent or not expressly specified in the FDA cleared or approved labeling (e.g., instructions for use, operator s manual or package insert) consult with your billing advisors or payers for advice on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service. Contact your Medicare contractor or other payer for interpretation of coverage, coding, and payment policies. Coverage and Authorization Services is available to respond to your coding questions toll-free at 800-292-2903. ICD-9-CM 1 Diagnosis Codes Diagnosis codes are used by both physicians and hospitals to document the indication for the procedure. Urinary Symptoms 788.20 Retention of urine, unspecified 788.21 Incomplete bladder emptying 788.29 Other specified retention of urine 788.31 Urge incontinence 788.41 Urinary frequency Attention to Device 2 V53.02 Fitting and adjustment of neuropacemaker (brain, peripheral nerve, spinal cord) ICD-9-CM 1 Procedure Codes Hospitals use ICD-9-CM 1 procedure codes for inpatient services. Lead Insertion or 04.92 Implantation or replacement of peripheral neurostimulator lead(s) Replacement 3 Generator Implantation 86.94 Insertion or replacement of single array neurostimulator pulse generator, not specified or Replacement 3 as rechargeable Lead Removal 04.93 Removal of peripheral neurostimulator lead(s) Generator Removal 86.05 Incision with removal of foreign body or device from skin and subcutaneous tissue 1. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is maintained by the National Center for Health Statistics and the Centers for Medicare and Medicaid Services. 2. Code V53.02 is used as the principal diagnosis when patients are seen for routine device replacement and maintenance. A secondary diagnosis code is then used for the underlying condition. 3. For a device replacement, coding guidelines do not allow removal of the old device to be coded together with implantation of the new device. 1

HCPCS II Device Codes 1 (Non-Medicare) These codes are utilized by the entity that purchased and supplied the medical device, DME, drug, or supply to the patient. For implantable devices, that is typically the facility. These HCPCS II device codes can be used by hospitals for billing outpatient services to non-medicare payers and by ASCs for billing non-medicare payers. Contact your local payer for specific billing instructions. For Medicare billing instructions for medical devices, see the Device C-Codes (Medicare) below. Test Lead A4290 Sacral nerve stimulation test lead, each Lead L8680 Implantable neurostimulator electrode, each Pulse Generator L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension Patient Programmer L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only 1. Healthcare Common Procedure Coding System (HCPCS) Level II codes are maintained by the Centers for Medicare and Medicaid Services. More information can be found at: http://www.cms.hhs.gov/medhcpcsgeninfo/01_overview.asp#topofpage. Device C-Codes (Medicare) 1,2 Hospitals assign C-codes when billing Medicare for medical devices in the outpatient setting. Use of C-codes is mandatory for Medicare hospital outpatient claims. Note that, unlike regular HCPCS II device codes, the extension is separately codable using C-codes. ASCs, however, usually should not assign or report HCPCS II device codes for devices on claims sent to Medicare. Medicare generally does not make a separate payment for devices in the ASC. Instead, payment is packaged into the payment for the ASC procedure. ASCs are specifically instructed not to bill HCPCS II device codes to Medicare for devices that are packaged. 3 Test Lead C1897 Lead, neurostimulator test kit (implantable) Leads C1778 Lead, neurostimulator (implantable) Pulse Generator (non-rechargeable) C1767 Generator, neurostimulator (implantable) non-rechargeable Patient Programmer C1787 Patient programmer, neurostimulator Extension C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable) Lead Introducer C1894 Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser 1. Device C-codes are HCPCS Level II codes and are maintained by the Centers for Medicare and Medicaid Services. A complete list of C-codes is available at: http://www. cms.hhs.gov/hcpcsreleasecodesets/anhcpcs/list.asp#topofpage. 2. Although other payers may also accept C-codes, regular HCPCS II device codes are generally used for billing non-medicare payers. 3. ASCs should report all charges incurred. However, only charges for non-packaged items should be billed as separate line items. For example, the ASC should report its charge for the pulse generator. However, because the generator is a packaged item, the charge should not be reported on its own line. Instead, the ASC should bill a single line for the implantation procedure with a single total charge, including not only the charge associated with the operating room but also the charges for the generator and all other packaged items. Because of a Medicare requirement to pay the lesser of the ASC rate or the line-item charge, breaking these packaged charges out onto their own lines can result in incorrect payment to the ASC. (See the Medicare Claims Processing Manual, Chapter 14, section 40, see also MLN Matters, SE0742, p. 9-10.) 2 Commonly Billed Codes

Device Edits (Medicare) Medicare s Consolidated Device Edits require that when specific CPT procedure codes for device implantation are billed, associated HCPCS II codes for the devices must also be billed. 1 When a hospital outpatient bill is received that contains one of the specific CPT procedure codes without one of the required HCPCS II codes, the claim is returned to the provider for correction. The edits also work in reverse; when a device HCPCS II code is present on the bill, the associated CPT procedure code must also be present. CPT Procedure Code CPT Code Description 2 64561 Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 64581 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 64590 3 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling Associated HCPCS II Codes C1897 L8680 C1778 L8680 C1767 L8686 HCPCS II Code Description Lead, neurostimulator test kit (implantable) Implantable neurostimulator electrode, each Lead, neurostimulator (implantable) Implantable neurostimulator electrode, each Generator, neurostimulator (implantable) non-rechargeable Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension 1. Device edits can be found at: http://www.cms.hhs.gov/hospitaloutpatientpps/02_device_procedure.asp#topofpage. The edits are updated once a quarter. 2. CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. 3. In edit logic, procedure code 64590 can also be paired with device code C1820, neurostimulator generator with rechargeable battery, as well as with L8685, single array rechargeable, L8687 dual array rechargeable, and L8688 dual array non-rechargeable.. As noted above, InterStim generators are single array and non-rechargeable. Commonly Billed Codes 3

Physician Coding and Payment Effective June 1, 2010 November 30, 2010 CPT Procedure Codes Physicians use CPT codes for all services. Under Medicare s Resource-Based Relative Value Scale (RBRVS) methodology for physician payment, each CPT code is assigned a point value, the relative value unit (RVU), which is then converted to a flat payment amount. Procedure CPT Code and Description 1 2010 Medicare RVUs 2 2010 Medicare National Average 3 For physician services provided in: 4 Physician Facility Physician Office 5 Office 5 Facility Test Stimulation 6 FDA labeling for InterStim Therapy requires a percutaneous test stimulation, and if that test is inconclusive, then the surgical lead may be used for test stimulation. 64561 Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 64581 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 28.37 11.32 $1,046 $417 N/A 21.88 N/A $807 Imaging Guidance 7 76000-26 Fluoroscopy, up to one hour N/A 0.24 N/A $9 Implantation 6,8 Revision/ Removal 6,8 64581 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 64585 Revision or removal of peripheral neurostimulator electrodes 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver N/A 21.88 N/A $807 See note 9 4.62 See note 9 $170 8.12 4.14 $299 $153 See note 9 3.63 See note 9 $134 Chart continued on next page 4 Commonly Billed Codes

Physician Coding and Payment CPT Procedure Codes continued Procedure CPT Code and Description 1 2010 Medicare RVUs 2 2010 Medicare National Average 3 For physician services provided in: 4 Physician Facility Physician Office 5 Office 5 Facility Analysis/Programming Note: In the office, Analysis and Programming may be furnished by a physician, practitioner with an incident to benefit, or auxiliary personnel under the direct supervision of the physician (or other practitioner), with or without support from a manufacturer s representative. The patient or payer should not be billed for services rendered solely by the manufacturer s representative. Contact your local carrier or payer for interpretation of applicable policies. Evaluation and Management Note: An office visit can only be billed separately when a full-scale, separately identifiable evaluation and management service takes place in addition to Analysis and Programming. The use of evaluation and management codes may require a -25 modifier and must meet separate coding requirements as well as documentation requirements. 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/ transmitter, without reprogramming 95972 Electronic analysis of implanted neurostimulator pulse generator system; complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour 99211 99215 Office or other outpatient visit 1.45 0.62 $53 $23 2.81 2.10 $104 $77 0.53 3.66 0.25 2.91 $20 $135 $9 $107 Chart continued on next page Commonly Billed Codes 5

Physician Coding and Payment CPT Procedure Codes continued 1. CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. 2. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B (for CY 2010), 74 Fed. Reg. 61738-62188 (finalized November 25, 2009). The total RVU as shown here is the sum of three components: physician work RVU, 2010 transitioned practice expense RVU, and malpractice RVU. 3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2010 is $36.8728. On June 25, 2010 the President signed into law HR 3962. This provides a 2.2% increase to the Physician Medicare Fee Schedule from June 1, 2010 through November 30, 2010. The bill may be found at: http://www.govtrack.us/congress/bill.xpd?bill=h111-3962. Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. 4. The RVUs shown are for the physician s services and payment is made to the physician. However, there are different RVUs and payments depending on the setting in which the physician rendered the service. Facility includes physician services rendered in hospitals, ASCs, and SNFs. Physician RVUs and payments are generally lower in the Facility setting because the facility is incurring the cost of some of the supplies and other materials. Physician RVUs and payments are generally higher in the Physician Office setting because the physician incurs all costs. 5. N/A shown in Physician Office setting indicates that Medicare has not developed RVUs in the Non-facility setting because the service is typically performed in a facility (e.g., in a hospital). However, if the local contractor determines that it will cover the service in the office setting, then it is paid using the Facility RVUs at the Facility rate, per the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B (for CY 2010), 74 Fed. Reg 62015 (finalized November 25, 2009). NA shown in the Facility setting indicates that the service is not paid to the physician in a hospital or ASC, because the service is expected to be performed by employees of the hospital or ASC instead. 6. Surgical procedures are subject to a global period. The global period defines other physician services that are generally considered part of the surgery package. The services are not separately coded, billed, or paid when rendered by the physician who performed the surgery. These services include preoperative visits the day before or the day of the surgery, postoperative visits related to recovery from the surgery for 10 days or 90 days depending on the specific procedure, treatment of complications unless they require a return visit to the operating room, and minor postoperative services such as dressing changes and suture removal. 7. Fluoroscopy may be billed separately if performed with placement of the tined lead (64581 only). 8. For a replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the old device to be coded together with implantation of the new device. 9. RVUs exist for this code in the non-facility (office) setting. However, they are not displayed because generator implantation and replacement customarily take place in the facility setting. 6 Commonly Billed Codes

Hospital Outpatient Coding and Payment Effective June 1, 2010 December 31, 2010 CPT Procedure Codes Hospitals use CPT codes for outpatient services. Under Medicare s APC methodology for hospital outpatient payment, each CPT code is assigned to one of about 820 ambulatory payment classes. Each APC has a relative weight that is then converted to a flat payment amount. Multiple APCs can be assigned for each claim depending on the number of procedures coded. Procedure CPT Code and Description 1 APC 2 APC Title 2 SI 2,3 Relative Weight 2 2010 Medicare National Average 2,4 Test Stimulation FDA labeling for InterStim Therapy requires a percutaneous test stimulation, and if that test is inconclusive, then the surgical lead may be used for test stimulation. 64561 Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 64581 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 0040 Percutaneous Implantation of Neurostimulator Electrodes 0061 Laminectomy, Laparoscopy, or Incision for Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve S 65.7095 $4,418 S 86.5171 $5,818 Imaging 76000 Fluoroscopy, up to one hour N/A N/A Q1 N/A N/A Guidance 5,6 Lead Implantation 64581 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 0061 Laminectomy, Laparoscopy, or Incision for Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve S 86.5171 $5,818 Generator Implantation or Replacement 7 64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 0039 Level I Implantation of Neurostimulator Generator S 206.1011 $13,858 Revision or Removal of Lead or Generator 7 64585 Revision or removal of peripheral neurostimulator electrodes 0687 Revision/Removal of Neurostimulator Electrodes T 19.6381 $1,320 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver 0688 Revision/Removal of Neurostimulator Pulse Generator Receiver T 28.6636 $1,927 Chart continued on next page Commonly Billed Codes 7

Hospital Outpatient Coding and Payment CPT Procedure Codes continued Procedure CPT Code and Description 1 APC 2 APC Title 2 SI 2,3 Relative Weight 2 2010 Medicare National Average 2,4 Analysis/ Programming Note: In the office, Analysis and Programming may be furnished by a physician, practitioner with an incident to benefit, or auxiliary personnel under the direct supervision of the physician (or other practitioner), with or without support from a manufacturer s representative. The patient or payer should not be billed for services rendered solely by the manufacturer s representative. Contact your local carrier or payer for interpretation of applicable policies. 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance, and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/ transmitter, without reprogramming 95972 Electronic analysis of implanted neurostimulator pulse generator system; complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour 0218 Level II Nerve and Muscle Tests 0692 Level III Electronic Analysis of Devices S 1.1965 $80 S 1.6000 $108 Chart continued on next page 8 Commonly Billed Codes

Hospital Outpatient Coding and Payment CPT Procedure Codes continued Procedure CPT Code and Description 1 APC 2 APC Title 2 SI 2,3 Relative Weight 2 2010 Medicare National Average 2,4 Evaluation and Management Note: A clinic visit can only be billed separately when a full-scale, separately identifiable evaluation and management service takes place in addition to analysis and programming. The use of evaluation and management codes may require a -25 modifier and must meet separate coding requirements as well as documentation requirements. 99201 Office or other outpatient visit, new patient, problem focused 99202 Office or other outpatient visit, new patient, straightforward 99203 Office or other outpatient visit, new patient, low complexity 99204 Office or other outpatient visit, new patient, moderate complexity 0604 Level 1 Hospital 0605 Level 2 Hospital 0606 Level 3 Hospital 0607 Level 4 Hospital 99205 Office or other outpatient 0608 Level 5 Hospital visit, new patient, high complexity 8 99211 Office or other outpatient visit, established patient, minimal 99212 Office or other outpatient visit, established patient, straightforward 99213 Office or other outpatient visit, established patient, low complexity 99214 Office or other outpatient visit, established patient, moderate complexity 99215 Office or other outpatient visit, established patient, high complexity 8 0604 Level 1 Hospital 0605 Level 2 Hospital 0605 Level 2 Hospital 0606 Level 3 Hospital 0607 Level 4 Hospital V 0.8593 $58 V 1.0337 $70 V 1.3222 $89 V 1.6830 $113 V 2.4853 $167 V 0.8593 $58 V 1.0337 $70 V 1.0337 $70 V 1.3222 $89 V 1.6830 $113 1. CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. 2. Changes to the Hospital Outpatient Prospective Payment System and CY 2010 Payment Rates, 74 Fed. Reg. 60316-60983 (finalized November 20, 2009). 3. Status Indicator (SI) shows how a code is handled for payment purposes. S = always paid at 100% of rate; T = paid at 50% of rate when billed with another higherweighted T procedure; V = visit, paid at 100% of rate. 4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor ($67.24 for 2010) as published in the Federal Register, Volume 74, Number 226, November 20, 2009, and revised via the Centers for Medicare and Medicaid Services (CMS) update to the Addenda A&B under the Affordable Care Act on May 18, 2010. The updated addenda may be found at: http://www.cms.gov/hospitaloutpatientpps/au/list.asp#topofpage. The payment is adjusted by the Wage Index for each hospital s specific geographic locality. Therefore, payment will vary from the stated national average Medicare payment levels. 5. Fluoroscopy may be billed separately if performed with placement of the tined lead (64581 only). 6. Status Q1 indicates that code 76000 is conditionally packaged. Although payable in a separate APC in certain unusual circumstances, it is designated as packaged into the primary service when submitted with another code with status indicators S, T, V, or X. When assigned with the lead implantation code, which is status S, code 76000 is packaged and not separately payable. 7. For a device replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the old device to be coded together with implantation of the new device. 8. More broadly, these codes have status indicator Q3. Status indicator Q3 shows that the higher level clinic visits may be part of a composite APC if billed with observation services. Otherwise, however, within the context of services related to neurostimulation therapy, the codes will typically be paid separately under the APCs, status indicators, and rates shown. Commonly Billed Codes 9

Hospital Inpatient Coding and Payment Effective October 1, 2010 September 30, 2011 Medicare MS-DRG Assignments Under Medicare s MS-DRG methodology for hospital inpatient payment, each inpatient stay is assigned to one of about 745 diagnosis-related groups, based on the ICD-9-CM codes assigned to the diagnoses and procedures. Each MS-DRG has a relative weight that is then converted to a flat payment amount. Only one MS-DRG is assigned for each inpatient stay, regardless of the number of procedures performed. The MS-DRGs shown are those typically assigned to the following scenarios. Procedure Scenario ICD-9-CM Procedure Codes Implant or Replacement Whole system (generator and leads) or leads only 4 Generator (86.94) plus leads (04.92); or leads only (04.92) Other Procedures 5,6 Generator implantation only (86.94) Lead removal only (04.93) MS- MS-DRG Title 1,2 Relative DRG 1 Weight 1 673 Other Kidney and Urinary Tract Procedures W MCC 674 Other Kidney and Urinary Tract Procedures W CC 675 Other Kidney and Urinary Tract Procedures W/O CC/MCC 981 Extensive OR Procedure Unrelated to Principal Diagnosis W MCC 982 Extensive OR Procedure Unrelated to Principal Diagnosis W CC 983 Extensive OR Procedure Unrelated to Principal Diagnosis W/O CC/MCC FY11 Medicare National Average 3 2.9260 $16,339 2.0934 $11,690 1.3379 $7,471 5.0634 $28,275 2.9402 $16,418 1.7767 $9,921 1. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2011 Rates, 75 Fed. Reg. 50041 50681 (finalized August 16, 2010). 2. W MCC in MS-DRG titles refers to secondary diagnosis codes that are designated as major complications or comorbidities. MS-DRGs W MCC have at least one major secondary complication or comorbidity. Similarly, W CC in MS-DRG titles refers to secondary diagnosis codes designated as other (non-major) complications or comorbidities, and MS-DRGs W CC have at least one other (non-major) secondary complication or comorbidity. MS-DRGs W/O CC/MCCs have no secondary diagnoses that are designated as complications or comorbidities, major or otherwise. Note that some secondary diagnoses are only designated as CCs or MCCs when the conditions were present on admission, and do not count as CCs or MCCs when the conditions are acquired in the hospital during the stay. 3. Payment is based on the average standardized operating amount ($5,164.11) plus the capital standard amount ($420.01) as published in Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2011 Rates, 75 Fed. Reg. 50451 (finalized August 16, 2010). Note that CMS may subsequently revise these rates via a correction notice. The payment rate shown is the standardized amounts for facilities with a wage index greater than one. The average standard amounts shown also assume facilities receive the full quality update. The payment will also be adjusted by the Wage Index for your specific geographic locality. Therefore, payment for your area will vary from the stated Medicare national average payment levels shown. 4. For implantation or replacement of InterStim, the driver in DRG assignment is the lead code 04.92. The same MS-DRGs are assigned based on this code, regardless of whether the generator is also implanted. 5. In DRG logic, the codes for InterStim generator implantation and lead removal are designated as nervous system procedures. When a urinary system diagnosis is used, the mismatch DRGs of 981, 982, and 983 are assigned. These DRGs are valid and payable. 6. The scenario of generator removal as the only procedure is not shown. Code 86.05 for removal of the generator only is not considered a significant procedure for the purpose of DRG assignment. When this is the only procedure performed, a non-surgical (i.e., medical) DRG is assigned to the stay according to the principal diagnosis. 10 Commonly Billed Codes

ASC Coding and Payment (Medicare) 1 Effective June 1, 2010 December 31, 2010 CPT Procedure Codes ASCs use CPT codes for their services. Medicare payment for procedures performed in an ambulatory surgery center is based on Medicare s ambulatory patient classification (APC) methodology for hospital outpatient payment. Each CPT code designated as a covered procedure in an ASC is assigned the same relative weight, or a comparable weight, as under the hospital outpatient APC system. This is then converted to a flat payment amount using a conversion factor unique to ASCs. Multiple procedures can be paid for each claim. Certain ancillary services, such as imaging, are also covered when they are integral to covered surgical procedures, although they may not be separately payable. In general, there is no separate payment for devices; their payment is packaged into the payment for the procedure. 2 Procedure CPT Code and Description 3 Payment Indicator 4,5,6 Test Stimulation FDA labeling for InterStim Therapy requires a percutaneous test stimulation, and if that test is inconclusive, then the surgical lead may be used for test stimulation. 64561 Percutaneous implantation of neurostimulator electrodes, sacral nerve (transforaminal placement) 64581 Incision for implantation of neurostimulator electrodes, sacral nerve (transforaminal placement) Multiple Procedure Discounting 7 Relative 2010 Weight 4,6 Medicare National Average 4,6,8 H8 N 83.6795 $3,504 H8 N 113.8180 $4,766 Imaging Guidance 9 76000 Fluoroscopy, up to one hour N1 N/A N/A N/A Lead Implantation Generator Implantation or Replacement 10 Revision or Removal of Lead or Generator 10 64581 Incision for implantation of neurostimulator electrodes, sacral nerve (transforaminal placement) 64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 64585 Revision or removal of peripheral neurostimulator electrodes 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver H8 N 113.8180 $4,766 H8 N 306.8087 $12,847 A2 Y 15.9745 $669 A2 Y 22.4431 $940 Chart continued on next page Commonly Billed Codes 11

ASC Coding and Payment (Medicare) CPT Procedure Codes continued 1. The surgical codes listed are designated as ASC-Covered Surgical Procedures for CY 2010 for Medicare. Code 76000 is designated an ASC-Covered Ancillary Services Integral to Covered Surgical Procedures. Medicare s list of covered surgical procedures and ancillary services is available at: http://www.cms.hhs.gov/ascpayment/. 2. ASCs should assign the CPT code for the procedure. However, ASCs are specifically instructed not to bill HCPCS II device codes to Medicare for packaged devices. ASCs should report all charges incurred but only charges for non-packaged items should be billed as separate line items. For example, the ASC should report its charge for the pulse generator but because the generator is a packaged device, the charge should not be reported on its own line. Instead, the ASC should bill a single line for the implantation procedure with a single total charge, including not only the charge associated with the operating room but also the charges for the generator and all other packaged items. Because of a Medicare requirement to pay the lesser of the ASC rate or the line-item charge, breaking these packaged charges out onto their own lines can result in incorrect payment to the ASC. (See the Medicare Claims Processing Manual, Chapter 14, section 40, see also MLN Matters, SE0742, p. 9-10.) 3. CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. 4. Changes to the Ambulatory Surgical Center Payment System and CY 2010 Payment Rates, 74 Fed. Reg. 60316-60983 (finalized November 20, 2009), and corrected by Changes to the Ambulatory Surgical Center Payment System and CY 2010 Payment Rates, 74 Fed. Reg. 69502-69676 (corrected December 31, 2009), and revised via the Centers for Medicare and Medicaid Services (CMS) per the Affordable Care Act on June 1, 2010. The revision is available on the CMS website at http://www.cms.gov/ ASCPayment/11_Addenda_Updates.asp#TopOfPage. 5. The Payment Indicator shows how a code is handled for payment purposes. A2 = surgical procedure, subject to transitional weight; H8 = device-intensive procedure, subject to transitional weight; N1 = packaged service, no separate payment. 6. Calendar Year 2008 was the first year in which Medicare payment to ambulatory surgery centers was based on hospital outpatient APCs. For some procedures, transitional payment formulas are in effect until 2011, blending factors from the prior ASC system and the APC system. The transition may cause weights for some procedures to vary significantly from year to year through 2011 until final rates are achieved. As shown, rates for 2010 are determined by multiplying the 2010 weight by the ASC conversion factor ($41.873 for 2010). For all procedures, the payment is then adjusted by the Wage Index for each facility s specific geographic locality. Therefore, payment will vary from the stated national average Medicare payment levels. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. 7. When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for the second and all subsequent procedures. These procedures are marked Y. However, procedures marked N are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures. 8. Medicare should be billed using a CMS-1500 form. 9. Fluoroscopy may be billed separately if performed with placement of the tined lead (64581 only). 10. National Correct Coding Initiative (NCCI) edits do not allow removal of the old device to be coded together with implantation of the new device. professional.medtronic.com United States of America Medtronic Neuromodulation 710 Medtronic Parkway Minneapolis, MN 55432-5604 USA Tel. 763-505-5000 Toll-free 1-800-328-0810 Europe Medtronic International Trading Sàrl Route du Molliau 31 Case Postale CH-1131 Tolochenaz Switzerland Tel. +41-21-802-7000 Asia-Pacific Medtronic International, Ltd. Suite 1602 16/F Manulife Plaza The Lee Gardens, 33 Hysan Avenue Causeway Bay Hong Kong Tel. 852-2891-4456 Australia Medtronic Australasia Pty. Ltd. 97 Waterloo Road North Ryde NSW 2113 Australia Tel. +61-2-9857-9000 www.medtronicneuro.com.au Canada Medtronic of Canada Ltd. 6733 Kitimat Road Mississauga, Ontario L5N 1W3 Canada Tel. 1-905-826-6020 UC201002978b EN NI9805b Medtronic, Inc 2010. Printed in the USA 10/10