Refer to the Novitas Local Coverage Determination (LCD) L35112, Implantable Infusion Pump, for reasonable and necessary requirements and frequency limitations.
The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
A physician’s service will not be utilized to fill the pump with the drug to be infused when dispensed by the pharmacy to the patient in claims submitted to the A/B MAC. Pharmacies, suppliers and providers may not bill Medicare Part B for drugs dispensed directly to a beneficiary for administration “incident to” a physician service, such as refilling an implanted drug pump. These claims will be denied.
Pharmacies may not bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary. When these drugs are administered in the physician’s office to the beneficiary, these drugs can be billed to Medicare only if the physician purchases the drugs from the pharmacy and the drugs are represented as an expense to the physician. Pharmacies may not bill Medicare Part B under the “incident to” provision.
When a patient receives two or more types of drugs for different reasons, such as Baclofen for spasticity and morphine for pain, diagnoses to support each of the reasons must be correlated on the claim.
Coding Information
Use the CPT/HCPCS codes listed below for the following conditions:
- Chemotherapy for Liver Cancer (J7999KD [compounded], E0782, E0783, E0785, E0786, 36260, 36261, 36262 and 96522)
- Antispasmodic Drugs for Severe Spasticity (J0475KD [non-compounded baclofen], J7999KD [compounded baclofen], E0782, E0783, E0785, E0786, 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 62369, 62370, 95990 and 95991)
- Coverage of Other Uses of Implanted Infusion Pumps (E0782, E0783, E0785, E0786 and various drugs)
- Opioid Drugs for Treatment of Chronic Intractable Pain (J7999KD [compounded], E0782, E0783, E0785, E0786, 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 62369, 62370, 95990 and 95991)
Refer to the Local Coverage Article, A54100 Compounded Drugs Used in an Implantable Infusion Pump, for additional coding and billing information regarding compounded drugs used in an implantable pump.
When a significant separately identifiable evaluation and management (E/M) service is performed, the appropriate E/M code should be reported utilizing modifier 25 in addition to the chemotherapy administration or non-chemotherapy injection and infusion service. For an E/M service provided on the same day, a different diagnosis is not required.
Repetitive infusions for the same patient for the same diagnosis and the same therapy may be billed with the EJ modifier appended to the subsequent infusion drug code(s).
- Although not required on the claim, the presence of an EJ modifier will alert the Contractor that not all of the original intake information used to establish the initial medical necessity of the infusion pump therapy may have been included in the progress note of the current subsequent service.
Drug Wastage
When a portion of the drug is discarded, the medical record must clearly document the amount administered and the amount wasted. The documentation must include the date, time, amount of medication wasted, and the reason for the wastage.
JW Modifier Requirement:
Effective 01/01/2017, per CR 9603, when billing for Part B drugs and biologicals (except those provided under CAP), the use of the JW modifier to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patient’s medical record. For more information see our website at www.Novitas-solutions.com.
