Local Coverage Article Billing and Coding

Billing and Coding: Implantable Infusion Pumps for Chronic Pain

A55323

Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
A55323
Article Title
Billing and Coding: Implantable Infusion Pumps for Chronic Pain
Article Type
Billing and Coding
Original Effective Date
09/01/2016
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2022 American Dental Association. All rights reserved.

Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

An implanted infusion pump for chronic pain is covered by Medicare when used to 1) administer opioid drugs, singly or in combination with other opioid or non-opioid drugs, 2) intrathecal or epidural route; 3) for treatment of severe chronic intractable pain of malignant or nonmalignant origin in patients who have a life expectancy of at least three (3) months, and 4) the pain has been proven to be unresponsive to less invasive medical therapy.

In order to be considered medically reasonable and necessary, all of the following criteria must be met and clearly documented in the beneficiary’s medical record:

    • The administration of the medication must require the intrathecal or epidural route and be effective on a long-term basis and
    • Oral or subcutaneous medication treatment are ineffective or complicated by unacceptable side effects and
    • The patient's medical condition must require the use of an infusion pump for pain relief due to failure of other treatment modalities and
    • The type and dosage of the medication must reasonably be expected to alleviate or reduce the pain effects.

In addition, an evaluation by an orthopedic surgeon, neurologist, neurosurgeon, oncologist or other specialist familiar with the underlying disease is required to validate that other treatments have failed to alleviate the pain and no other reasonable options are available at the time of the evaluation. Documentation that the patient is unresponsive to less invasive medical therapy shall be kept in the patient's medical record and made available upon Medical Review request.

If the above criteria have been met, a preliminary trial of intraspinal opioid or non-opioid drug administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate acceptable pain relief, degree of side effects including effects on the activities of daily living, and patient acceptance and compliance.

Any drug(s) used to fill the implantable pump must be appropriate for the treatment of the individual patient. Drugs compounded for the special needs of a patient may be covered. Drugs filling the pump are often obtained singly or mixed with other drugs from compounding pharmacies. Unless the medications are administered in the exact concentrations available from national pharmaceutical companies, the medications will be considered as compounded.

FDA approved drugs used for indications other than what is accepted on the official Prescribing Information label may be covered under Medicare if the contractor determines the use to be medically accepted, taking into consideration the major drug compendia, authoritative medical literature, and/or accepted standards of medical practice. The following are examples of medications that are approved for off-label intrathecal use. This list of drugs is not an all-inclusive list.

    • Clonidine (Duraclon) (J0735-KD)
    • Bupivacaine (J3490-KD)
    • Sufentanil (J3490-KD)
    • Methadone (J1230-KD)

Contraindications to coverage: Implantation of an infusion pump is contraindicated under the following circumstances:

      1.The patient has a known allergy or hypersensitivity to the drug being used;
      2. Patients who have an infection in particular an infection at or near the implantation site; and
      3. Patients whose body size is insufficient to support the weight and bulk of the device.

The patient’s medical record documentation must support the reasonable and necessary requirements as outlined under the indications and limitations of coverage. The patient’s history must indicate that he/she has not responded adequately to noninvasive methods of pain control such as:

    • Systemic opioids; or
    • Combination of oral analgesics (including opioids) plus other drugs known to relieve pain such as:
      • muscle relaxants,
      • clonidine,
      • anti-depressants,
      • anti-seizure medication or
      • others known to medicate pain; or
    • Attempts to eliminate physical and behavioral abnormalities which may cause an exaggerated reaction to pain.

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.

At the time of the pump refill and/or the pump interrogation and/or the pump reprogramming, documentation should include at a minimum:

    • The pump status before and after the refill,
    • The patient’s response to the current medication dose and rate,
    • The reasons for any change in dose or the types of medications,
    • A reassessment of the patient's overall condition and treatment goals (this may be reported as an E&M service),
    • Proof that all applicable "incident to" requirements are met, and
    • Proof that any medication billed to Medicare represents a cost to the physician or group accepting Medicare payment.

A preliminary trial of the intrathecal/epidural opioid drug or non-opioid administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate adequate acceptable pain relief. The degree of side effects (including the effects on the activities of daily living) and the patient’s acceptance of and compliance with the therapy must be documented in the patient's record.

Legible physician’s medical documentation must be maintained in the patient’s medical record and meet the criteria contained in this article. The subsequent determination that the medical record is lacking the justification for the services and/or that the documentation of the services are illegible will result in a denial as not reasonable and necessary.

A periodic reassessment of the patient should be performed according to the needs of the patient and the applicable medical standards. 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.

Compounded drugs are contractor priced under Medicare Part B. Noridian will reimburse compounded drugs for use in implanted infusion pumps by multiplying the price per mcg or mg in the table below by the total number of mcg or mg of each drug used to refill the pump. In addition to the combined allowable calculated by the dosage detailed, a pharmacy compounding fee of $60 per refill will be included in the total allowable for the refill. When these drugs are provided in the hospital outpatient department by providers paid under OPPS, no separate payment is made for these drugs. The payment allowance is packaged into the payment for other services provided on the claim.

Drug Name Drug Fee Measure      
Baclofen $0.0030 per mcg      
Bupivacaine $0.0400 per mg      
Clonidine $0.0010 per mcg      
Droperidol $0.0013 per mcg      
Fentanyl PF $0.0072 per mcg      
Hydromorphone $0.1300 per mg      
Ketamine $0.0048 per mcg      
Lidocaine $0.0400 per mg      
Meperidine $0.0600 per mg      
Methadone $0.0600 per mg      
Midazolam Hcl $1.1500 per mg      
Morphine Sulfate $0.0500 per mg      
Ropivacaine $0.071 per mg      
Sufentanyl $0.0900 per mcg      
Tetracaine $0.0400 per mg      
Ziconotide $9.105 per mcg      
Compounding Fee $60.000 per cartridge      


Resources

  1. Angel IF, Gould HJ, Carey ME. Intrathecal morphine pump as a treatment option in chronic pain of nonmalignant
    origin. Surg Neurol. Jan 1998;49(1):92-8.
  2. Chang HM. Chronic Pain, Cancer Pain Management. Med. Clinics of North America. May 1999;83(3):712-36.May 1999;83(3):712-36.
  3. Dougherty P, Staats PS. Intrathecal Drug Therapy for Chronic Pain: From Basic Science to Clinical Practice. Anesthesiology. Dec 1999;91(6):1891-918.
  4. Fanciullo GJ, Rose RJ, Lunt PG, Whalen PK, Ross E. The state of implantable pain therapies in the United States: a
    nationwide survey of academic teaching programs. Anesth Analg. Jun 1999;88(6):1311-6.
  5. Gilmer-Hill HS, Boggan JE, Smith KA, Frey CF, Wagner FC, Eein LS. Intrathecal morphine delivered via
    subcutaneous pump for intractable pain in pancreatic cancer. Surg Neurol. Jan 1999:51(1):6-11.


Coding Information

CPT/HCPCS Codes

Group 1

(16 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
62325 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
62327 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
62350 IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY
62351 IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITH LAMINECTOMY
62355 REMOVAL OF PREVIOUSLY IMPLANTED INTRATHECAL OR EPIDURAL CATHETER
62360 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; SUBCUTANEOUS RESERVOIR
62361 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; NONPROGRAMMABLE PUMP
62362 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING
62365 REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION
62367 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITHOUT REPROGRAMMING OR REFILL
62368 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING
62369 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND REFILL
62370 ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND REFILL (REQUIRING SKILL OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL)
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 REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR FOR DRUG DELIVERY, SPINAL (INTRATHECAL, EPIDURAL) OR BRAIN (INTRAVENTRICULAR), INCLUDES ELECTRONIC ANALYSIS OF PUMP, WHEN PERFORMED; REQUIRING SKILL OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL
J7999 COMPOUNDED DRUG, NOT OTHERWISE CLASSIFIED

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A


N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2023 R11

Updated prices for Prialt (Ziconotide) and Ropivacaine per quarterly ASP Drug file update:

Effective 01/01/2023 - 03/31/2023

Prialt (Ziconotide) = $9.105

Ropivacaine = $0.071

10/01/2022 R10

Updated prices for Prialt (Ziconotide) and Ropivacaine per quarterly ASP Drug file update:

Effective 10/01/2022 - 12/31/2022

Prialt (Ziconotide) = $9.065

Ropivacaine = $0.092

07/01/2022 R9

Updated prices for Prialt (Ziconotide) per quarterly ASP Drug File Update:

Effective 07/01/2022 – 09/30/2022
Prialt (Ziconotide) = $9.078
Ropivacaine = $0.071

04/01/2022 R8

Updated prices for Prialt (Ziconotide) per quarterly ASP Drug file update:

Effective 04/01/2022 - 06/30/2022

Prialt (Ziconotide) = $8.998

Ropivacaine ASP is unchanged from January quarter.

01/01/2022 R7

Updated prices for Prialt (Ziconotide) and Ropivacaine per quarterly ASP Drug file update:

Effective 01/01/2022 - 03/31/2022

Prialt (Ziconotide) = $9.054

Ropivacaine = $0.069

Formatting was updated throughout the article.

10/01/2021 R6

Updated prices for Prialt (Ziconotide) and Ropivacaine per quarterly ASP Drug file update:

Effective 10/01/2021 - 12/31/2021
Prialt (Ziconotide) = $8.686
Ropivacaine = $0.080

01/01/2021 R5

Updated prices for Prialt (Ziconotide) and Ropivacaine per quarterly ASP Drug file update:

Effective for 1/1/2021 - 3/31/2021
Prialt (Ziconotide) = $8.480
Ropivacaine = $0.066

Effective for 4/1/2021 - 6/30/2021
Prialt (Ziconotide) = $8.395
Ropivacaine = $0.083

Effective for 7/1/2021 - 09/30/2021
Prialt (Ziconotide) = $8.658
Ropivacaine = $0.076

10/01/2020 R4

Updated prices for - Prialt (Ziconotide) = $8.171 per mcg and Ropivacaine = $0.0730 per mg per the updates effective 10.01.2020 per the ASP Drug File

09/01/2016 R3

Converted to Billing and Coding article only. No changes to article content.

09/01/2016 R2

11/07/2018: Verbiage added indicate Compounded drugs are contractor priced under Medicare Part B and additional verbiage added: When these drugs are provided in the hospital outpatient department by providers paid under OPPS, no separate payment is made for these drugs. The payment allowance is packaged into the payment for other services provided on the claim.

 

09/01/2016 R1 Change in verbiage from may to must regarding intraspinal opioid or non-opioid drug administration. Replacement of CPT code 62318 with 62325 and 62319 with 62327.

Associated Documents

Related Local Coverage Documents
N/A
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
12/23/2022 01/01/2023 - N/A Currently in Effect You are here
09/29/2022 10/01/2022 - 12/31/2022 Superseded View
07/21/2022 07/01/2022 - 09/30/2022 Superseded View
04/05/2022 04/01/2022 - 06/30/2022 Superseded View
01/07/2022 01/01/2022 - 03/31/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A