Anesthesia Coding Alert

Step 2: Permanent placement Correct coding for the pump's placement depends on the anesthesiologist's role in implantation, how you coded the initial trial and whether the pump is programmable. Possibilities include 00630 (Anesthesia for procedures in lumbar region; not otherwise specified), 62361 (Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump) and 62362 ( programmable pump, including preparation of pump, with or without programming). You may need to append modifier -26 (Professional component) or -58 (Staged or related procedure or service by the same physician during the postoperative period) to the procedure code, depending on the anesthesiologist's role in the case.

Step 3: Follow-up and maintenance How often a patient returns to the pain specialist for pump maintenance depends on several factors, including the size of the permanent pump and the medication dosage. This is the area of pump coding that has changed in 2003, with CPT adding a new maintenance code and revising one of the existing codes to balance the addition.

Before you can code correctly for pump follow-up and maintenance, you need to know the ins and outs of the new and updated codes. These include:

The AMA's CPT Changes 2003: An Insider's View supports Olson's opinion of this important distinction. "The refill and maintenance of the different pumps is very different in terms of risk knowledge required skill required and severity of potential complications " the book states. "The addition of code 95990 provides a more granular system of codes that reflect the work time and intensity for the refill and maintenance of pumps providing spinal or brain infusion (epidural intrathecal intraventricular) versus systemic infusion."

You will report 95990 for patients with chronic intractable pain such as those with cancer multiple sclerosis failed back syndrome or radicular pain.

Coders such as Kim Arnett CPC with the physician group Georgia Anesthesiologists PC in Marietta Ga. expect to use the new code frequently. "We have many patients who have undergone permanent implantation of programmable pumps (62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir) " she says. "Now 95990 will be used for the refill process (along with other applicable codes) for analysis and/or reprogramming of the pump."

You may need to append modifier -26 (Professional component) to 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) and 62368 ( with reprogramming) if the physician performs only the professional component of the procedure. Use these codes with 95990 to report pump analysis and reprogramming.

Always know the physician's role in whatever pump procedure stage you're coding so you can correctly report services. The anesthesiologist may be involved with only one stage of the process or he may provide surgical anesthesia during the pump placement then work in a pain management capacity during the patient's maintenance phase.

For example Olson remembers coding for a pain management physician who worked with a neurosurgeon on cases involving pain-pump placement. "My physician would sometimes do anesthesia for the placement then take over the case for the maintenance and refilling " she says. "We had to be careful to match the provider type with the service that was provided (i.e. 07 for providing anesthesia 02 for surgical 01 for medical)."

"The neurosurgeons in our area generally don't provide pump maintenance as a service to the patient " Arnett adds "so physicians in our pain practice see them for pump maintenance. The neurosurgeons and pain specialists usually work together to ensure the patient receives the best care for each portion of the process."

Aside from coding the procedure itself correctly reporting the medication the anesthesiologist or pain specialist administers is also important. Morphine is most commonly prescribed for pumps but the physician may use several other drugs. The type of pain being treated the patient's long-term prognosis and the cost and success of previous treatment will influence the medication selection. Possibilities frequently include J2275 (Injection morphine sulfate [preservative-free sterile solution] per 10 mg) J0475 (Injection baclofen 10 mg) or J0476 (Injection baclofen 50 mcg for intrathecal trial).

Pump refill drugs are often a mixed compound. The physician places two or more drugs in the pump such as several medications for pain control or an anti-nausea medication along with morphine. Since they are mixed compounds the standard injection codes are not correct to use for compounds unless the carrier specifies it Arnett says. Her group generally uses J3490 (Unclassified drugs) to report pump refills and submits a copy of the pharmacy prescription and receipt to the insurance carrier. Some Medicaid carriers have other codes for specific drugs and don't allow for J3490. Check your local carrier's guidelines for the best medication code to use.

You should list the drug charge and refill service on the same claim form. Arnett's practice also states in block 19 of the CMS 1500 form that it has attached a compound drug prescription. They then submit a paper claim with a copy of the pharmacy prescription and receipt as backup.

On a final note regarding pump medication coding Medicare usually bundles the refill kits (A4220 Refill kit for implantable infusion pump) with the compound drug mixture price instead of reimbursing for it separately Arnett says.

Guidelines regarding correct coding for pump placement and maintenance can vary widely between carriers so you should be familiar with their policies Olson Parman and Arnett urge. "Meticulous documentation" supporting medical necessity for the service is a must Olson says. "Know what type of paperwork your carriers want submitted with claims in order not to delay payments " she suggests.

Knowing the carrier's guidelines regarding place of service is also important. Some carriers such as Medicare only reimburse codes 96530 62367 and 62368 when the service is provided at a nonfacility site (e.g. a physician office or patient's home).

Arnett doesn't believe that her pain practice group had many problems with reimbursement for pump refills using the old version of 96530. Instead its challenge lies in reimbursement for the drug compound. But the changes do separate and clarify coding for pump refills and maintenance which helps you meet your goal of reporting services in the most accurate way possible.