Anesthesia Coding Alert

The three-stage process of using a permanent implantable pump (trial insertion and evaluation, permanent placement, and ongoing maintenance) can present a significant coding dilemma for anesthesia practices. The challenge is that how each stage is performed largely determines how the next one is coded.
 
Clearing Up Trial-pump Coding (Stage One)
 
"During a trial, you're trying to demonstrate that the implantable pump (intrathecal or infusion) is the way to go for a patient," explains Abraham Rivera, MD, CEO of the Pain Management Medical Group in Albany, N.Y. "To clearly show that, you have to prove to yourself that the patient has had at least 50 percent reduction in pain that cannot be achieved with oral medications or any other means. You prove that you're on the right track by showing that the patient's pain scores came down 50 percent, and that the oral medication was cut by 50 percent during the trial-pump usage."

A trial can be done three different ways: single injection of medication, continuous infusion, or tunneled catheter with external pump. "I think the confusion starts primarily with billing a trial," says Devona Slater, CMCP, president of Auditing for Compliance and Education Inc., a consulting firm in Leawood, Kan., that focuses on physician compliance plans in anesthesia and pain management. "The correct code for permanent placement, and whether modifiers must be appended, depends on how the trial is coded." 

The length of a trial period is determined by the physician and the patient's clinical condition, Slater says. She explains that a single-shot trial period could be one day, a continuous infusion trial two or three days, and a trial with the catheter tunneled with an external pump three days to two weeks.

 

1. Single injection of medication (or single-shot) trial: According to Rivera, you can do a trial by just performing a single-shot intraspinal morphine injection and observing the patient for 24 hours. However, Rivera says, a 24-hour trial period might not truly reflect the patient's pain situation. If the anesthesiologist decides on this trial method, depending on the location of the injection, code the procedure with CPT 62310 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or CPT 62311 (... lumbar, sacral [caudal]. 
 
2. Continuous infusion: "The next best thing to a single injection is to place a temporary intraspinal catheter over three to five days and slowly infuse morphine, reproducing what the actual pump would do," he adds. Some physicians choose longer trial periods, allowing the patient to return home with the trial pump in order to acquire a truer picture of its effectiveness. People might tolerate the pump for a few days as inpatients, but find that the pump doesn't manage the pain as effectively once they resume the daily activities of home. That's why physicians such as Rivera believe that the "ideal" pump trial lasts two weeks. The trial is usually a continuous ambulatory delivery (CADD) pump the patient wears at home during normal activities to determine more accurately whether an implantable pump will bring significant relief.

You can use the following codes for continuous infusion trial catheters that are in place for more than one day: 

62318 (injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or ubarachnoid; cervical or thoracic) or

 

62319 (... lumbar, sacral [caudal]).

 

3. Tunneled catheter with external pump: Physicians use this procedure when they anticipate a successful trial in which the catheter remains in place for an indefinite time. If this is the choice, use 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).

 

Note: If a patient is visited for daily management of a pump or catheter, use code 01996 (daily management of epidural or subarachnoid drug administration) for any days after the original procedure, codes 62319, 62318 or 62350.

If a trial fails (because, for example, the pain is not opiate sensitive), the physician removes the catheter, a surgical procedure that might take several hours because the catheter is buried and anchored, Rivera says. If the anesthesiologist, rather than a surgeon, removes the catheter, use 62355 (removal of previously implanted intrathecal or epidural catheter). However, if the anesthesiologist only provides anesthesia during the procedure and does not remove the catheter, report 00300 (anesthesia for procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified).

 

 

If the trial succeeds, the next step is permanent pump implantation. Coding for this procedure might vary with the anesthesiologist's role in the implantation and how the trial was coded. "In a situation where the anesthesiologist places the catheter and a surgeon creates a pocket for the pump, tunnels the catheter and connects it to the pump, the anesthesiologist bills for the anesthesia used in the procedure with 00630 (anesthesia for procedures in lumbar region; not otherwise specified),"Slater says. This code carries a base of eight units plus time. 

However, if an anesthesiologist in your group implants the pump and also provides the anesthesia, report 62362 (implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming) or 62361 (... non-programmable pump) in addition to the anesthesia code. 

You might also have to use modifier -26 (professional component) when coding permanent pump placement. If the pain management physician places the pump, some coders do not use the modifier. But if another physician, such as a neurosurgeon, places the pump and the anesthesiologist programs it and assists, you could use modifier -26 to indicate that someone else created the pocket, and the anesthetist performed only the professional component of the procedure. Slater also points out that a trial conducted with a tunneled catheter and external pump (code 62350) has a 90-day global period. If permanent placement occurs after the 90-day trial period, append modifier -58 (staged or related procedure or service by the same physician during the postoperative period). Modifier -58 is not required if the procedure is done within the 90-day period.

 

 

How often patients go to the anesthetist for pump maintenance depends on the size of the permanent pump and the administered dosage. A nurse, with physician oversight, normally handles follow-up care and pump refills. Many physicians use a device that tests the programmable pump for battery life, amount of drug remaining and other factors. Those tests allow servicing the pump -- either refilling, reprogramming to adjust the dose, or leaving it alone. 

 
Three codes apply to maintenance of programmable pumps:

96530 (refilling and maintenance of implantable pump or reservoir) is the primary code to report pump refilling and maintenance at a visit. 

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) is used along with modifier -26 to show the physician's involvement in the visit when no changes are made to the pump. 

62368 (... with reprogramming) is coded with modifier -26 when the physician adjusts the pump, such as refilling the pump or altering the rate or frequency at which medication is administered. If the pump is not programmable, use 96530 to report maintenance services.

Most pump reservoirs hold 20 ml, but Rivera says only 18 ml is usable. "How often we refill the pump depends on how much medication in the reservoir is consumed," he says. "I try to keep refills at least one month apart, but not more than three. You don't want to leave the drug in the reservoir longer than three months because the drug could become unstable."

 

 

Besides understanding how to code correctly for all the services related to a trial, permanent placement and follow-up care, you should be aware of two other areas to cover for adequate payment  billing for the drug used in the pump and obtaining precertification for the permanent placement procedure. 

Codes commonly used for infusion drugs are J2275 (injection, morphine sulfate [preservative-free sterile solution], per 10 mg) for morphine, J0475 (injection, baclofen, 10 mg) for baclofen and J3490 (unclassified drugs) for miscellaneous drugs. The challenge is determining how to compute and bill the different drugs. Morphine (the most commonly prescribed drug for pumps) is billed by concentration, so coders might have to sharpen their math skills to determine the units to charge. For example, if you are filling an 18-ml pump with morphine at a concentration of 10 mg/ml, you determine the chargeable amount as follows:

18 ml x 10 mg  =  180
10 mg                    10

 

In this example, the total units of medication to charge for is 18. By contrast, baclofen, another common intrathecal medication, is billed at one unit for each ampule used, so calculations are more straightforward.

If different drugs are mixed for the infusion, Slater says you must file with the unclassified medication code (J3490) and attach a copy of the patient's medication invoice to document and explain what was administered. Only FDA-approved medications are reimbursed, therefore explanatory documentation must accompany any deviation from the approved list.

Both Slater and Rivera say that getting adequate payment for implantable pump services is particularly challenging if the procedure was not previously approved. While Slater advises gaining carrier precertification for  the pump trial, Rivera adds that you also want prior approval for the final procedure. "Medicare considers this service part of your covered contract and will not authorize payment," he notes. "And a blanket approval from private carriers simply stating 'intraspinal pump for morphine administration approved' is not enough for adequate or consistent payment of all cases or costs. Carriers must specify that they will pay equipment costs separately from the procedure without discounting. If you don't have this in writing prior to the patient's treatment, you will usually not be paid."