Neurology & Pain Management Coding Alert

Question: Medicare denied our claim with 62368 and 95991 for implanting a programmable pump and filling the infusion pump. When I called to ask for information, the representative said we could append a modifier and be paid for both procedures. How should we handle this?

Answer: The reason for your denial lies in the code descriptors and CCI (Correct Coding Initiative) edits.

Code 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) applies to existing pumps. You coded for a pump implantation, which makes 62368 incorrect. Instead, you should report 62362 (Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming).

Look closely at the descriptor and you'll see that the initial implantation service of the infusion pump includes the initial filling, whether the healthcare provider programs the pump during that encounter or later. You would be noncompliant to report the "refill" and "reprogram" CPT codes when the pump is initially implanted because reimbursement for 62362 includes both the pump fill and programming. That inclusion is the basis for CCI considering 62368 and 95991 (Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal [intrathecal, epidural] or brain [intraventricular]; administered by physician) bundled as components of the more comprehensive 62362 code.

Modifier: CCI edits that carry a modifier indicator of "1" can sometimes be unbundled and each reported. When applicable, you can append modifier 59 (Distinct procedural service) or another appropriate choice and include documentation that justifies payment for both services (such as when the analysis and reprogramming are performed at different encounters on the same date of service). That might be what the Medicare representative you spoke with referred to, but you aren't able to try that in your situation.