Anesthesia Coding Alert

Question: How do I bill for an in-office (owned and operated by the pain management specialist) refill and reprogramming of a pump? We are using 62368-26 and 96530. Is this correct?

Illinois Subscriber

Answer: Codes 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) and 96530 (refilling and maintenance of implantable pump or reservoir) without modifier -26 (professional component) are appropriate in most states. Modifier -26 is required in Massachusetts, New York and New Hampshire.

Many procedures combine a professional, or physician component, and a technical component. Modifier -26 is appended to CPT codes to indicate that the physician performed the professional component of a service only.

Note: HCFAs fee schedule, available on the HCFA Web site (www.hcfa.gov), indicates whether a code should be broken down into professional and technical components.

When a procedure takes place at a hospital, or when the physician does not own the equipment, modifier -26 is usually required.

Note: Modifier -TC signifies that only the technical component was provided.

In this case, the procedure has been performed in a freestanding physicians office (owned and operated by a physician). Therefore, modifier -26 should not be appended to 62368 in any case, but rather the global fee (combining professional and technical components) should be billed.

Note: The HCFA fee schedule lists 62368-26 as a status code A service, meaning it is covered and relative value units for the procedure have been assigned. The global code 62368, however, is a status code C service, meaning that payment policies are carrier-specific.

The refill or reprogramming may be denied initially because the implantation of the pump has a 90-day global period; therefore, 62368 and 96530 should be appended with modifier -58 (staged or related procedure) when performed during the post-operative period.

HCPCS code A4220 (refill kit for implantable infusion pump) should also be used to bill for the refill kit because some Medicare carriers consider this bundled into the refill and reprogramming; you should check with your local carrier.