Trialing - Chronic Pain


1. Q: Do I need to preauthorize the trial?

A. We do recommend preauthorizing the entire procedure including the trial phase and pump implantation. This can be done with one request. Please remember, Medicare does not preauthorize services. For questions about Medicare, we recommend that you contact your local Medicare contractors.

2. Q. What are the reimbursement implications of conducting single-shot versus more extensive trials with a temporary external infusion pump for determining implantable infusion pump candidacy for a patient with chronic intractable pain?

A. Many public and private coverage policies for implantable infusion pumps (including Medicare's national policy and those from the local carriers) require that the trials for determining appropriate implantable infusion pump candidates include evaluation of the treatment's effects, both positive and negative, on the patient's "activities of daily living." Specifically, Medicare's national policy (CIM 60-14) states that for the use of an implantable infusion pump for the treatment of chronic intractable pain, "A preliminary trial of intraspinal opioid drug administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate adequately acceptable pain relief and degree of side effects (including the effects on activities of daily living) and patient acceptance."

In fact, Trailblazer Health, one of the Part B Carriers, has written that "CIM 60-14 does not permit the use of a single injection"for the preliminary trial. Therefore, Medicare (and other payers that have a similar requirement) can refuse to pay for implantable infusion pumps used for chronic pain when a single-shot trial is conducted. Since Medicare does not preauthorize, providers may not learn of this denial until after the implant surgery is performed and payment is subsequently denied. Furthermore, providers may encounter difficulties obtaining preauthorization for implanting an infusion pump from private payers unless the more extensive form of trialing is completed and documented. Thus, from a coverage perspective, an extended trial with a temporary intrathecal/epidural catheter evaluating the pain relief and side effects of the infused opioid drug during activities of daily living would be preferred and should be considered. For more information, see the Physician Services Section of this guide.

3. Q. My physician does not tunnel the catheter for the trialing phase. How should this be coded?

A. Depending on whether the physician uses a catheter or single injections over a period of time, the appropriate CPT code range is 62310 - 62319. For more information, see the Physician Services Section of this guide.

4. Q. Is trialing payable in the Ambulatory Surgery Center (ASC) setting?

A. Yes, however the catheter and supplies are included in the ASC facility payment. In most cases, there will be no additional reimbursement for the supplies.

5. Q. If my physician uses the AGILECATH™ for the trialing phase, how should this be coded?

A . The AGILECATH™ is only indicated for external use. Therefore, if it is used in the trialing phase, the appropriate code(s) are 62318 and 62319 depending on the spinal location.

6. Q. What C-codes should be used for the trialing supplies?

A. Effective January 1, 2005, hospitals must use C-codes, even though use of the C-code may not result in additional payment. There is a C-code, C1755 (Catheter, intraspinal) that may be used to describe a tunneled trial catheter. The external pump has a HCPCS code of E0781 (Ambulatory infusion pump), which facilities should reflect on their claim forms.

7. Q. If I am using a tunneled catheter for the trial, and the patient complains of persistent pain, can I separately bill for reprogramming the MicroJect?

A. Yes. If the visit is due to a recurrence of pain, even though it is within the 90-day global time frame, you may separately report your services.

8. Q. What are the coding and billing options for MicroJect reprogramming?

A. There is no specific code that accurately describes reprogramming for external infusion pumps. Based upon a query to the AMA and the association's current philosophy to base coding on precise procedure descriptions, the unlisted procedure code 64999 should be used and a SPECIAL REPORT detailing the procedure, equipment and supplies should accompany the claim.

9. Q. Should the procedure be modified with -58 to indicate a staged procedure?

A. Yes. If the trial is considered stage one and the implant of the pump is considered stage two, the modifier -58 should be appended to the stage two procedure(s).



Implantation - Chronic Pain

1. Q. What is the life expectancy of the pump?

A. The pump is expected to last for a lifetime. For more details, please refer to the warranty information provided with your pump.

2. Q. If I remove a tunneled trial catheter and replace it with the permanent catheter, can I bill for removal and implantation?

A. Yes. Removal of a previously implanted epidural or intrathecal catheter is coded 62355. Implantation of a permanent tunneled epidural or intrathecal catheter without laminectomy is coded 62350. If both procedures are performed on the same day, modifier -51 (Multiple Procedures) should be added to the less significant procedure.

3. Q. Can the infusion pump be implanted in the ambulatory surgery center?

A. There are no specific payment provisions under the Medicare program to compensate the ASC facility for the cost of the pump and supplies. We recommend verifying coverage of the implantable pump with your local Medicare contractors in advance of the procedure. For non-Medicare patients, we recommend clarifying this question during the preauthorization process.

4. Q. Does the non-programmable infusion pump have a corresponding C-code?

A. Yes. C1891 may be used as a coding option for outpatient procedures for Medicare-only claims. However, this code is not eligible for pass-through payment. Also, the permanent HCPCS code E0782 should be used for non-Medicare claims.

5. Q. Should the procedure be modified with -58 to indicate a staged procedure?

A. Yes. If the trial is considered stage one and the implant of the pump is considered stage two, the modifier -58 should be appended to the stage two procedure(s).

6. Q. Will hospitals receive additional payment for the morphine used?

A. No. Under the Medicare program, payment for the morphine is included in the facility payment.



Refill & Maintenance - Chronic Pain

1. Q. How should pump refill and maintenance be coded?

A. As of January 1, 2004, refill and maintenance of an implantable infusion pump should be coded with CPT code 95990 when performed by a professional who is not a physician and CPT code 95991 when performed by a physician.

2. Q. Are CPT codes 95990 or 95991 appropriate for non-programmable pumps?

A. Yes. CPT codes 95990 or 95991 are appropriate for programmable and non-programmable pumps.

3. Q. When billing for a refill and maintenance visit (95990 or 95991), can I also bill an E&M code?

A. Advice received from a telephone query to the AMA CPT Information Services indicates that you can bill the appropriate E&M code with 95990 or 95991, if a separately identifiable evaluation and management service is provided and properly documented in the patient's record. Please note that the appropriate modifier (-25 - Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) must be appended to the E&M code.

4. Q. Will physicians receive additional payment for the morphine or baclofen used during the refilling procedure?

A. Yes. Physicians should code for the morphine or baclofen. Review payer policies for coding advice, as they may vary.

5. Q. What are the coding options for the morphine used in an infusion pump?

The morphine primarily is coded one of two ways:

1. J3490 (unclassified drugs) is recommended for infusion pump refills by some carriers. A 2003 article by Cigna's Part B carrier states that J2275 (injection, preservative free morphine sulfate per 10 mg) is not intended for the quantities used in infusion pump refills and therefore, J3490 is the recommended code.

2. J2275 (injection, morphine sulfate, preservative free solution per 10 mg) is the other code that has been used.

6. Q. What are the differences in payment for morphine?

A. The payment for morphine depends upon the coding and whether it is being administered through durable medical equipment (pump).

1.When coded as J2275-KD (administered through durable medical equipment), the 2005 Medicare reimbursement allowable for the morphine is $4.39/10 mg.

2. When coded as J3490, Medicare reimburses the morphine (and saline if added) based upon the invoice cost.

7. Q. How should we code for flushing of a tunneled catheter?

A. Accessing and flushing the tunneled catheter is included in the E&M service as part of managing the patient or as part of the refill and maintenance (95990 or 95991).

8. Q. What are the coding and billing options for bolus injections?

A. There is no specific code that accurately describes bolus injections into infusion pumps. Based upon a query to the AMA and the association's current philosophy to base coding on precise procedure descriptions, the unlisted procedure code 64999 should be used and a SPECIAL REPORT detailing the procedure, equipment and supplies should accompany the claim.

9. Q. If the morphine is compounded, how should the drug be coded?

A. When billing for compounded drugs, J3490 must be billed with 95990 or 95991 (refill and maintenance) on the same claim, or the claim will be denied.

10. Q. Is the refill kit (A4220) for implantable infusion pumps separately payable by Medicare?

A. No. The refill kit (A4220) is considered bundled into the refill and maintenance service and excluded from coverage under most Part B Local Carrier policies. Non-Medicare payers may provide benefits; we recommend clarifying during the preauthorization process.

11. Q. What are the coding and billing options for dye studies to check the patency of the catheter for an infusion pump?

A. There is no specific code that accurately describes dye studies for the catheter used with infusion pumps. Based upon a query to the AMA and the association's current philosophy to base coding on precise procedure descriptions, the unlisted procedure code 64999 should be used and a SPECIAL REPORT detailing the procedure, equipment and supplies should accompany the claim.

12. Q. When there isn't an exact code for my services, can I just use the code with a description that is the "closest" match?

A. No. CPT codes are established and maintained by the American Medical Association (AMA). In today's coding environment, the AMA does not want providers to use a CPT code if the code does not accurately describe the procedure or service. The AMA is emphasizing this philosophy in their CPT 2004 book. Under the section titled Instruction for Use of CPT, the AMA has added the following statement:

"Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code."

13. Q. How can an ASC receive appropriate Medicare reimbursement for providing implantable infusion pumps?

A. If an ASC is enrolled with the Medicare program as a Durable Medical Equipment (DME) supplier, the facility can bill for the infusion pump in addition to its services. The ASC must submit two separate claims, one to their Part B carrier for the use of the facility and another to their DMERC for the implantable infusion pump. However, even with this option, an ASC usually cannot recuperate its cost of providing an implantable infusion pump (and many other implantable products) for a Medicare beneficiary at this time. Medicare has been ordered by Congress to study ASC reimbursement and the feasibility of changing to a system like the one for hospital outpatient reimbursement.

14. Q. What is the code for saline injected in to an infusion pump?

A. The HCPCS code is J2912 (Injection, sodium chloride, 0.9%, per 2 ml).

15. Q. Why is there a new modifier, KD, for drugs used in an implanted pump?

A. CMS now pays for drugs administered through Durable Medical Equipment (DME) at a higher rate than those infused another way (e.g. single-shot injection). Therefore, the KD modifier was added effective January 1, 2004 to be able to identify claims with drugs that should be paid at a higher level.



HAI System

1. Q. What is the life expectancy of the CODMAN 3000 Implantable Constant-Flow Infusion Pump?

A. The pump is expected to last a lifetime. For more details, please refer to the warranty information provided with your pump.

2. Q. Do I need to preauthorize the Codman 3000 Implantable Constant-Flow Infusion Pump?

A. Yes. We do recommend preauthorizing the procedure, however, please remember Medicare does not preauthorize services. For questions about Medicare, we recommend contacting your local Medicare contractors.

3. Q. How should the drug (FUdR) be coded?

A. J9200 is the appropriate code for Floxuridine, 500 mg.

4. Q. Does the hospital receive payment for the chemotherapy drug?

A. Under the Medicare program, if the drug is provided in the outpatient hospital setting, the hospital will receive payment. However, if the drug is provided in the inpatient hospital setting, payment for the drug is included in the DRG payment.

5. Q. Can the Codman 3000 Implantable Constant-Flow Infusion Pump be implanted in the Ambulatory Surgery Center (ASC)?

A. There are no specific payment provisions under the Medicare program to compensate the ASC facility for the cost of the pump and supplies. We recommend verifying coverage of the implantable pump with your local Medicare contractors in advance of the procedure. For non-Medicare patients, we recommend clarifying this question during the preauthorization process.

6. Q. Does the non-programmable infusion pump have a corresponding C-code?

A. Yes. C1891 should be used as a coding option for outpatient procedures for Medicare-only claims. However, this code is not eligible for pass-through payment. Also, the permanent HCPCS code E0782 should be used for non- Medicare claims.

7. Q. How should we code for flushing of the access catheter?

A. Routine flushing of a vascular access device with saline of heparin is considered part of the chemotherapy services and not reported separately.

8. Q. How should pump refill and maintenance be coded?

A. Refill and maintenance of an implantable hepatic arterial infusion pump should be coded with CPT code 96530.

9. Q. Is the refill kit (A4220) for implantable infusion pumps separately payable by Medicare?

A. No. The refill kit (A4220) is considered bundled into the refill and maintenance service and excluded from coverage under most Part B Local Carrier policies. Non-Medicare payers may provide benefits, we recommend clarifying during the preauthorization process.

10. Q. How do we code for the use of glycerin in the Codman 3000 Implantable Constant-Flow Infusion Pump?

A. Since there is no specific HCPCS code for glycerin, code J3490 (unclassified drug) is suggested. The use of this code requires that the invoice amount be entered on the claim.

11. Q. What forms of glycerin are available for use in the Codman 3000 Implantable Constant-Flow Infusion Pump?

A. Please consult the Redbook or the Physician’s Desk Reference (PDR) for glycerin options.

12. Q. What codes are used for giving a bolus injection of a chemotherapy drug through the Codman 3000 Implantable Constant-Flow Infusion Pump?

A. Advice received from the AMA CPT Information Service indicates that a bolus injection of chemotherapy drug through an implanted infusion pump should be coded as 96240 (Chemotherapy administration, intra-arterial, push technique) plus the appropriate code for the drug being administered (e.g., J9190 for 5FU).






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