Implantable Infusion Pumps for Chronic Pain
Implantable pain pumps are medical devices implanted under the skin. They deliver medication directly to the spinal cord used to manage chronic pain. Proper coding of implantable pain pump procedures is critical for accurate and compliant claims submitted for reimbursement for pain management services. For the purpose of today’s article, we are going to focus on implantable pain pump management services that occur in the office.
Ten things to consider:
- Are the services for refill and/or reprogramming of the device?
- Who is furnishing/providing the drug to be administered?
- Is the administered drug an expense to the practice plan? The patient? Or, the pharmacy?
- Was a separately identifiable E/M performed (i.e., for re-evaluation of the pump)?
- Who is performing the service?
- Who is the payer?
- Has someone verified the patient’s benefits?
- Do they have specific coding and billing policies for reimbursement?
- Is this a Medicare patient?
- Does this service meet “Incident-to” guidelines if not performed by the physician/ACP?
It cannot be emphasized enough how important it is to verify benefits with individual payers to verify their policies for reimbursement of these services. Especially, if they do not follow Medicare requirements. Commercial payer policies may have differing requirements for Advance Care Practitioners, “Incident-to”, and payment criteria for the service. It is always best to check with the patient’s plan, first.
Let’s review some of the guidance put out there by CMS (Centers for Medicare and Medicaid Services).
CMS Article – Implantable Infusion Pumps for Chronic Pain (A55239)
Right out of the gate, CMS wants you to know they are not allowing these services to be reported in a split-claim fashion. What does that mean? It means, everything relating to the service for refill or management, must be reported on the same claim. No component coding.
“All of the procedure codes that are related to the refilling and the management of the pump must be billed and documented on the same claim form, including the drugs that are being administered through the pump. The drugs are not to be billed on a separate claim form. IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 17 – Drugs and Biologicals at Chapter 17 MCPM . Chapter 32 Billing Requirements for Special Services at Chapter 32 MCPM .” (04/01/2023)
This means, the drug administered must be a practice expense for the physician performing the service. CMS requires proof of purchase as part of their documentation criteria for pump refill, and/or the pump interrogation, and/or the pump reprogramming.
Minimal Documentation Must Include:
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- The pump status before and after the refill,
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- The patient’s response to the current medication dose and rate,
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- The reasons for any change in dose or the types of medications,
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- A reassessment of the patient’s overall condition and treatment goals (this may be reported as an E&M service),
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- Proof that all applicable “incident to” requirements are met, and
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- Proof that any medication billed to Medicare represents a cost to the physician or group accepting Medicare payment.
CPT Coding:
95990 – Refilling and Maintenance of Implantable Pump or Reservoir for drug delivery, Spinal (Intrathecal, Epidural) or Brain (Intraventricular), includes electronic analysis of pump, when performed.
95991 – (All of the above) + Requiring skill of physician or other qualified health care professional
J7999 – Compounded Drug, NOC (Not Otherwise Classified)
E/M (Evaluation and Management)
Evaluation and management is not typically reported separately during the refill, interrogation, or reprogramming service. However, a periodic reassessment of the patient should be performed according to the needs of the patient and the applicable medical standards. If the E/M service is for reassessment, or for a separately identifiable problem, it may be reported with a -25 modifier.
According to CMS, “the frequency for interrogating and/or reprogramming the pump (62367 and 62368) should be supported by the patient’s symptoms. The frequency for refill must take into account the size of the pump and dosage of the medicine. Noridian has seen problems in the past that included unnecessary frequency of interrogation and refills of the pump every month despite having a pump of 2 or 3-month capacity.”
The AMA addressed in their July 2006 CPT Assistant Article when it is possible to report a separately identifiable E/M Service via (6) different clinical scenarios. I have provided an excerpt in Sway. This OIG Article demonstrates the perils of getting it wrong.
In an effort to keep the article short, I am going to refer you to the CMS LCD Article to read-up on all of the other hoops that are necessary to make this happen. The article gives very specific criteria for Medical Necessity, and failure to respond to certain therapies that must be in the record to support the need for this service. CDI (Clinical Documentation Improvement) is currently at work on a Tip Sheet. So check back for more on that.
We also have information regarding Drug Waste Documentation for Single Dose/Use (ppt), which applies to these services. Please check out this brief presentation if this information hasn’t already made it to your departmental faculty meeting.
CMS LCD Articles:
CMS LCD Policy Article A56695 (2022) (L33461)
CMS LCD Policy Article A56778 (2022) (L35112)
CMS LCD Policy Article, A54100 (2022)
If you have any questions, or would like more information, please contact [email protected].