Neurosurgery Coding Alert

Pain pumps often are used to manage a patients pain after spine surgery, but getting reimbursed for the procedures and extra work involved may be challenging. By documenting the ineffectiveness of other pain management attempts and establishing the medical necessity for the pump, neurosurgeons can decrease the chances for denials.

For example, a patient undergoes an extensive spine surgery and experiences severe postoperative pain. Standard medications are ineffective for treating her discomfort, and she does not respond to multiple injections of stronger substances for pain management. The neurosurgeon decides that a programmable pain pump must be installed to address her condition. The pump is implanted and successfully controls the patients pain.

Douglas Rammel, MHCM, chief executive officer of Associated University Neurosurgeons, Peoria, Ill., a seven-member neurosurgery group that installs as many as 10 pain pumps each year, says that one of the main reasons for denials is a lack of documentation that all other avenues of pain management have been tried and proven to be ineffective. Thats the first thing Medicare and most third-party payers will look for; the physician has to prove the medical necessity, says Rammel.

Beverly Trout, coding and reimbursement specialist for Associated University Neurosurgeons, says that patients ultimately requiring the implantation of a drug infusion pump present with a variety of chronic pain symptoms. Cancer patients, sufferers of nerve damage or nerve entrapment, or patients like the one described above, all meet the requirement of having chronic pain that does not respond to normal mechanisms of pain treatment.

The patients specific pain management needs determine the type of drug necessary for treatment, and the choice of a pump is made based on that information. For example, a morphine pump may be used with a cancer sufferer, while a baclofen pump would be more appropriate for spasticity.

Coding Pain Pump Implantation

Trout says that a typical coding scenario for the implantation of a pain pump will begin with code 62350 (implantation, revision, or repositioning of tunneled intrathecal or epidural catheter, for long-term pain management via an external pump or implantable reservoir/infusion pump; without laminectomy) for the percutaneous implantation. The catheter portion also may be implanted by laminectomy (62351).

Implantation of the actual pump is then coded. There are three different codes for implantation of pain pumps:

62360implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir) for subcutaneous reservoir

62361implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump) for a non-programmable pump

62362implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming) for programmable pumps.

Associated University Neurosurgeons generally uses programmable pumps (62362). Because the implantation of the catheter and the pump are done at the same time, Trout lists the highest reimbursable procedure (62362) first, followed by the 62350 with the modifier -51 (multiple procedures).

Dari Bonner, CPC, CPC-H, CCS-P, president of the coding consulting firm Exact Coding and Reimbursement in Port St. Lucie, Fla., and a national lecturer on coding, compliance and reimbursement, says that if the pain pump is implanted to control pain in the wake of a surgical procedure performed by the neurosurgeon and within the 90-day global surgical period, modifier -78 (return to the operating room for a related procedure during the postoperative period) would be used on codes 62362 and 62350 to show the relationship between the initial surgery, the implantation of the pump, and any other related charges during that time frame. For repeat procedures during the same day, use modifier -76 (repeat procedure by same physician) on codes 62362 and 62350.

Billing Pain Pump Maintenance

After the surgery there are other considerations. Patients return on a regular basis for the refilling, maintenance and potential reprogramming of the pump. Code 96530 (refilling and maintenance of implantable pump or reservoir) often is used for the refilling and maintenance. If reprogramming is needed to raise or lower the amount of the drug released by the pump, Trout generally uses 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). The codes for refilling, maintenance and reprogramming can be billed together and no modifier is required.

If electronic analysis of the pump without reprogram-ming proves necessary, use 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).

Trout reports that neurosurgeons use the J codes from HCPCS when billing for the drug, and the choice of code depends not only on the particular drug selected but also the amount of the drug used to refill the pump.

Trout says that from her experience, a patient rarely will present for refilling and maintenance of the pump within the 90-day global period for the pumps implantation. If this occurs, she would append modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to 62368 and 96530 to show that although the refilling, maintenance and reprogramming are related to the surgical procedure, they are still separate procedures and should not fall under the global period.

She cautions that some carriers may be more willing to reimburse under these circumstances than others, but, from her experience, the patient returning for this reason during the initial 90-day period is rare, and so it should not be an area of major concern if a neurosurgeons office is investigating the possibility of adding the implantation of pain pumps to the procedures commonly performed.

Trout adds that when the patient comes back to her office for the refilling/maintenance and possible reprogramming of the pump, the physician or the nurse always dictates a report detailing the amount of the drug that was used and all that occurred during the reprogram-ming. We have found that we get better results from insurance companies when we send a copy of that days dictation with the billing, says Trout. Her local Medicare carrier requires the documentation and claims with third- party payers have been reimbursed more rapidly when the dictation accompanies the bill.

Pain Pump Removal or Replacement

Trout says that pain pumps generally are implanted for long-term pain management and often are not removed at all. The catheter or the pump itself, however, may develop a problem and need to be replaced. Or conditions may arise when the catheter and pain pump need to be removed altogether, such as if the patient is not responding to the pump. Neurosurgeons should use 62365 (removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion) for removal of the pump and 62355-51 (removal of previously implanted intrathecal or epidural catheter; multiple procedures) for removal of the catheter.

To replace the pump and catheter, use the same codes given for the implantation of each and provide detailed operative notes to document the medical necessity for the procedure. The choice of a modifier to append to this procedure would depend on the time frame in which the replacement occurs.