General Surgery Coding Alert

Question: We have just started billing for the OnQ pain pump. Medicare is denying all of our claims. We found an article in the June 2006 General Surgery Coding Alert stating that we should not expect to get paid for the OnQ pain pump because we cannot charge separately for pump placement.

North Carolina Subscriber

Answer: When you can demonstrate medical necessity, Medicare will cover the cost of supplies for the OnQ pump. The local coverage determination (LCD) for the Part B carrier in North Carolina (BC/BS) specifies:

BCBSNC will provide coverage for continuous infusion of anesthesia to operative wound sites using a disposable pump when it is determined to be medically necessary and when medical criteria and guidelines shown below are met. Continuous infusion of anesthesia to operative wound sites using a disposable pump may be considered medically necessary as a technique for postoperative pain control for surgeries typically requiring oral or parenteral narcotics for pain relief.

In most cases, the supply codes for the pumps are a facility expense, not billed by the surgeon. The BCBSNC LCD states, -The disposable infusion pump (A4305, A4306) is a supply most commonly reported as a facility expense. Code E0781 is a non-disposable infusion pump that is usually rented, not purchased, and is not to be used for billing disposable infusion pumps.-

Although Medicare payers will cover supply costs when medically necessary, they will not reimburse separately for the work of implanting the pump. Here, again, are the BC/BS guidelines:

Payment for catheter insertion and removal to provide continuous delivery of a drug to a surgical site is included in the allowance for the surgery and, therefore, is not eligible for separate payment.

The LCD does go on to state: -There is no specific code describing insertion of the infusion catheter at the time of surgery. It is possible that an unlisted code will be billed (27599, 49999, 58999 are examples seen).-

Even if you do report an unlisted-procedure code, however, you will not receive additional reimbursement for the physician work of placing the pump because the service is bundled to (or, in the words of this particular LCD, -included in the allowance for-) the primary surgical service.