# 62368/62369/62370 confusion



## adamss

Recently we questioned if we were billing pain pump refills correctly at our practice.  We bill provider based billing so we have a professional and technical side.  What we had done in the past (Pre Jan 1 2012) was bill out our cpt 62368 for the reprogram and refill and a service code on the technical side for that service as well. We also bill out the med on our technical side.  

 The question was raised since the physican is not doing the pump refill, the nurse does, should we have billed the professional side with 62368? (which is now 62369 with the new code change).  Instead should we have billed the technical portion for the refill/reprogram and have had the physican bill an office visit (since he saw the patient before the nurse refilled the pump)

ALSO now that we have 62370 is this applicable in this situation?? or should it only be used when the doctor is preforming the refill him/herself, or is it applicable since he is in house and saw the patient, evaluated ect...

Ah too confusing.  anyone know?  have any good articles?  thanks!


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## dwaldman

62368 prior to 2012 and currently, does not include work of refilling the pump. If the nurse was performing the refill prior to 2012, you would use 95990, if reprogramming was also performed 62368 would be reported. In 2012, 62369 would describe refilling of the pump resevoir and reprogramming, 95990 would describe refilling of the pump and anaylsis without reprogramming. 62368 in 2012 is reprogramming/analysis without refill.

You should not bill office visit by the physician if the nurse refill the pump. In order to bill an office visit in addition to pump refill and/or reprogramming. A significant, separatley identifiable E/M service that would go above and beyond the pre and post work of doing a pump refill would have to be performed and modifier 25 would be added to office visit in that situation. But if the physician is seeing the patient and instructing the nurse to refill the pump with a certain dosage setting than you bill 62369 under the physician's NPI. The facility fee would be the same code 62369 under the facility NPI. 

Requiring physician skill, does not mean using for incident to billing. It would be a encounter where the physician performed it.  physician skill described in CPT Changes 2012 "requiring physician's skill because of difficult access or other medical issues or complex reprogramming of his pump. I noticed in the April 2012 AAPC Coding Edge, there will be an upcoming article on these codes which will be worth checking out. 
Per AMA CPT Changes 2012"

RESERVOIR/PUMP IMPLANTATION
 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 refill62368 with reprogramming 
(For refilling and maintenance of an implantable infusion pump for spinal or brain drug therapy, see 95990 - 95991)
 62369 with reprogramming and refill 
 62370 with reprogramming and refill (requiring physician's skill) 
(Do not report 62367 - 62370 in conjunction with 95990, 95991. For refilling and maintenance of a reservoir or an implantable infusion pump for spinal or brain drug delivery without reprogramming, see 95990, 95991)
Rationale
The AMA/Specialty Society RVS Update Committee (RUC) identified codes 62367, 62368, 95990, and 95991 in the "Codes Reported Together 75% or More" screen. As a result, the services described by these codes have been combined as appropriate by revising code 62367, adding two new codes to this code family, and revising codes 95990 and 95991. See the Medicine/Neurology and Neuromuscular Procedures/Other Procedures section of this book for an explanation of the revisions to codes 95990 and 95991.

Code 62367 has been revised to specify that it does not include refilling of a programmable, implanted pump that is used for intrathecal or epidural drug infusion. Codes 62369 and 62370 were added to this code family to report electronic analysis of a programmable, implanted pump for intrathecal or epidural drug infusion, including reprogramming and refilling of the pump. Code 62369 is reported when a physician's skill is not required to perform the service. Code 62370 should be reported when the service does require a physician's skill.

Codes 62367 - 62370 should not be reported with codes 95990 and 95991. Codes 95990 and 95991 should be reported for refilling and maintenance without reprogramming (when performed) on a reservoir or an implantable infusion pump for spinal or brain drug delivery.
Clinical Example (62367)
A 65-year-old male presents for an electronic analysis of an implanted infusion pump that delivers opiates and has successfully controlled his pain due to prostate cancer and metastases to multiple bone sites in the lower body and resultant bilateral leg and pelvic bone pain (rated 8/10). Because of the multiple sites of bone involvement and lack of response to chemotherapy, no radiation therapy or further chemotherapy is planned. His expected survival time from his cancer is 9 months. The electronic analysis of the implanted pump device, which determines the rate of infusion and the amount of morphine solution remaining in the pump reservoir, indicates a satisfactory infusion rate and residual volume; so no reprogramming or refill is needed.
Description of Procedure (62367)
Electronic analysis is performed to determine reservoir status, alarm status, and the drug prescription status. Because the electronic analysis of the implanted pump device indicates a satisfactory infusion rate and residual volume; no reprogramming or refill is needed.
Clinical Example (62369)
A 65-year-old male has prostate cancer and metastases to multiple bone sites in the lowerbody and resultant bilateral leg and pelvic bone pain. A permanent implantable subcutaneous programmable infusion pump and an intrathecal infusion catheter were implanted for a long-term intrathecal infusion of narcotic. Because of inadequate pain control, the patient now presents for refill and reprogramming of his pump, not requiring physician's skill.
Description of Procedure (62369)
The nurse fills the pump under physician supervision and then electronic analysis is performed to determine reservoir status, alarm status, and the drug prescription status. Electronic analysis of the pump function verifies the infusion rate. Based on the patient's evaluation, the pump is then reprogrammed to adjust the rate of infusion and control the increased level of pain. The pump alarm settings and reservoir levels are programmed as well as any changes made to the drug infusion concentration or mixture. Refill date estimates are also made.
Clinical Example (62370)
A 65-year-old male has prostate cancer and metastases to multiple bone sites in the lower body and resultant bilateral leg and pelvic bone pain. A permanent implantable subcutaneous programmable infusion pump and an intrathecal infusion catheter were implanted for a long-term intrathecal infusion of narcotic. Because of inadequate pain control the patient now presents for refill (requiring physician's skill because of difficult access or other medical issues or complex reprogramming of his pump).
Description of Procedure (62370)
Electronic analysis is performed to determine reservoir status, alarm status, drug prescription status. The subcutaneous pump is palpated and identified. The entire area over the pump is prepped and draped. Throughout all this procedure, sterile technique is meticulous to prevent infection. A pump refill kit is then opened and extra required supplies added to the kit. The solution's container is checked to be sure that the drug, the drug volume, and the drug's concentration are all correct according to what was ordered. Using sterile technique, the drug to be injected into the pump is then drawn from its transport vial into a sterile syringe using a filter needle. The syringe is then connected to a Huber needle with an extension tube in the kit. The needle is advanced and probed to find the actual center of the pump reservoir and advanced through the injection septum of the pump into the reservoir to the proper depth. The residual volume of the solution is aspirated from the pump/reservoir and is measured and checked against the medical records and/or pump status printout to make sure the entire volume of the pump/reservoir has been removed. The syringe containing the new solution attached to the tubing and then very slowly injected into the pump/reservoir. The patient is examined and pump/reservoir are then checked for any possible error in administration. The pump is then reprogrammed to adjust the rate of infusion and control the increased level of pain. The pump alarm settings and reservoir levels are programmed as well as any changes made to the drug infusion concentration or mixture. Refill date estimates are also made"

Prior 2012, CPT Assistant 
July 2006 page 1
Refilling and Maintenance of Implantable Delivery Systems 

The services for refilling and maintaining implantable delivery systems (infusion pumps or reservoirs) that include intrathecal, intraventricular, and epidural drug delivery are described by codes 95990, Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal(intrathecal, epidural) or brain (intraventricular), and code 95991, Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular); administered by physician. The refill and maintenance of these types of pumps differs from that of systemic infusion in terms of risks, knowledge required, skill required, and severity of potential complications. Hence, codes 95990 and 95991 allow a more specific description, which reflects the work, time, and intensity for the refill and maintenance of pumps providing spinal or brain infusion as opposed to intravenous systemic infusion. Code 95990 has no physician work value and describes the services reported by the nonphysician provider, while code 95991 is reported for the physician services provided in the refilling and maintenance of the implantable pump or reservoir. 

The electronic analysis and/or reprogramming of programmable implantable infusion pumps is reported separately by the use of CPT codes 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 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, when performed at the same session as the refill and maintenance of the implantable pump or reservoir. A parenthetical note following code 95990 instructs users to refer to these codes for analysis and/or reprogramming. A point of significant consideration with respect to programmable pumps is that they require reprogramming at the time of refill. 

Some ambiguity arises among the coding community when reporting codes 95990 and 95991 in addition to evaluation and management (E/M) services. It is important to note that the E/M service is not included in codes 95990 and 95991. If a significant, separately identifiable E/M service is performed, the appropriate E/M service code should be reported using modifier 25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service, in addition to codes 95990 and 95991. 

The following scenarios illustrate the appropriate reporting for an E/M service on the same day as the refill and maintenance of an implantable pump. Of vast importance is to note that these clinical scenarios are examples only. A particular patient encounter, depending on the specific circumstances, must be judged by the services provided by the physician for that particular patient. Reporting guidelines and polices may differ among individual payers; therefore, policies and required reporting guidelines should be obtained from each payer. 

Clinical Scenario 1

A patient with a history of a failed back syndrome presents to the pain clinic for a routine pump refill. She meets with the practice's registered nurse (RN), reports no new symptoms, and states that she has continued good pain control. The RN performs the refill of the spinal opioid delivery system. The physician sees the patient and reprograms the pump without changing the daily dosage. The patient is informed of her refill date and sent home. 

CPT code 95990 is reported for the refill and maintenance of the implantable pump provided by the practice's RN. Code 62368 is reported for the reprogramming. No E/M service is reported for this scenario. 

Clinical Scenario 2

A patient with a history of complex regional pain syndrome of the right lower extremity presents to the pain clinic for evaluation and refill of his pump. He is seen by the nurse for initial intake. The patient reports decreased libido, increased peripheral edema, and poor pain control. The nurse refills the pump. The physician sees the patient, reprograms the pump, orders laboratory tests to check for drug-induced hypogonadism, and recommends follow-up with the primary care provider for his peripheral edema and laboratory results. In addition, the physician adjusts the patient's oral medications to help with his pain. The physician spends 25 minutes counseling the patient. 

CPT code 95990 is reported for the refill of the pump performed by the nurse. Code 62368 is reported for the reprogramming by the physician. The appropriate level E/M service code is reported with modifier 25 appended for the counseling provided by the physician. 

Clinical Scenario 3 

A patient with a history of osteoporosis and multiple compression fractures presents to the clinic for a refill of her implanted spinal opioid delivery system. She meets with the physician, complains of slight worsening of pain since her last visit, and requests that the dosage be increased. The physician performs the refill and reprograms the pump with a 10% increase in daily dosage. The physician does not prescribe any medication and does not manage any other medical issues. 

CPT code 95991 is reported for the pump refill provided by the physician. Code 62368 is reported for the reprogramming. No E/M code is reported for this scenario. 

Clinical Scenario 4

This scenario is similar to Clinical Scenario 3, but the physician also manages the patient's complaints of shoulder pain secondary to osteoarthritis. He prescribes a nonsteroidal anti-inflammatory drug and recommends a follow-up visit in one month for an intraarticular shoulder injection. The physician spends a total of 10 minutes patient contact time taking a history and examining the shoulder. 

CPT code 95991 is reported for the refill of the pump provided by the physician. Code 62368 is reported for the reprogramming. The appropriate level E/M service code is reported with modifier 25 appended. 

Clinical Scenario 5

This scenario is similar to Clinical Scenario 4, but the physician elects to inject the shoulder (in addition to the pump refill) due to lack of response to previous conservative treatment. 

CPT code 95991 is reported for the refill of the pump provided by the physician. Code 62368 is reported for the reprogramming. Code 20610 is reported for the shoulder injection with modifier 59 appended to indicate that a distinct procedural service was performed by the same physician on the same date. The appropriate E/M service code is reported with modifier 25 appended. 

Coding Tip

In Clinical Scenarios 1 through 5, the physician may report also the supply of drugs with CPT code 99070, Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided), or the appropriate HCPCS Level II J code(s). 

Clinical Scenario 6

A patient presents for pump interrogation following an magnetic resonance imaging of the brain ordered by her primary care physician. The pump is interrogated by the practice's physician assistant (PA) and found to have no changes from the previous settings. No adjustments are made to the pump dosage. No physician is present in the office. 

Code 62367 should be reported for the pump analysis. It is important to check with individual third-party payer policy and reporting guidelines for services reported by a PA because these may vary among payers. 

Coding Update

Since the publication of the Coding Consultation in the November 2002 issue of CPT Assistant, codes 95990 and 95991 have been added to the CPT code set to describe the refill and maintenance of an implantable pump or reservoir for drug delivery to the spine or brain. Newly renumbered code 96522 (deleted 96530) is intended solely for chemotherapy pump refills. Based upon the previous published information, there appears to be a perception in the coding community that codes 95990 and 95991 cannot be separately reported with code 62368. A parenthetical reference following code 95991 has been added to instruct users to report codes 62367-62368 for analysis and/or reprogramming of an infusion pump. It would be appropriate, therefore, to report codes 95990 and 95991 in addition to code 62368 when performed at the same session. Thus, this information supersedes the previously published information from the Questions and Answers section of the November 2002 CPT Assistant (see Medicine: 96530, 62368 on page 10).


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## adamss

thanks for the information I also found a good webinar through medtronic if anyone else is looking for information.


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## Brandyleigh6440

Could you please send me a link to the webinar you found? 
Thanks! Brandy


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## mhstrauss

I also just recently found out about the Medtronic Spine Academy webinars...and just got an email that they will no longer do these   What a bummer... 
I was able to get a few in the last month or so, and they were some of the most informative I've ever seen.


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## terra.duck@gmail.com

*62368/62369/62370*

Is anyone receiving denials from Medicaid on 62370? It is bundling with 99212 and 95991??????


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## dwaldman

62369/62370 would be reported for reprogramming and refill
95990/95991  states should not be reported with 62369/62370. 95990/95991 would be reported if only analysis of the pump was performed in addition to the refill.

The majority of cases I see, there is not a separate identifiable E/M service being provided and typically don't bill an E/M. But there can be instances where an E/M which above and beyond the pre and post work and separately identifiable and modifier 25 can be appended to the E/M service. We don't recognize prescribing oral medications for the same condition that the patient is having pump refilled as separately identifiable.

Below is from AMA CPT Changes 2012
Codes 95990 and 95991 were revised to include electronic analysis of a pump for intrathecal, epidural, or intraventricular drug delivery when performed in conjunction with refilling and maintenance of the pump. Code 95991 has been further revised to clarify that physician's skill is required by changing the language from "administered by physician" to "requiring physician's skill." 

The parenthetical note following code 95990 directing users to codes 62367 and 62368 for analysis and/or reprogramming of implantable infusion pump has been deleted. The parenthetical note following code 95990 directing users to code 96522 for refill and maintenance of implanted infusion pump or reservoir for systemic drug therapy has also been deleted. Two parenthetical notes have been added following code 95991. The first note instructs users not to report codes 95990 and 95991 in conjunction with codes 62367 - 62370 and to report codes 62367 - 62370 for analysis and/or reprogramming of implantable infusion pump. The second note is a cross-reference directing users to report code 96522 for refill and maintenance of an implanted infusion pump or reservoir for systemic drug therapy (eg, chemotherapy).

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## ItsUp2U

*Requiring Physician Skill*

With regards to 62369 and 62370 (Requiring Physician skills), what code is appropriate for a Certified Physician's Assistant?


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## dwaldman

My understanding is you would use 62369 because a PA-C is considered non-physician provider.


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