Neurosurgery Coding Alert

Through documenting the ineffectiveness of other pain management and spacticity treatments and choosing appropriate procedure and diagnosis codes for pain pumps (62350-62368), neurosurgeons may overturn denials and eliminate the risk of future lost reimbursement.

Document Medical Necessity

Proper documentation is the first thing Medicare and most third-party payers look for when reviewing claims for pain pumps, says Tamara Middleton, CCS-P, an analyst specialist for the centralized abstracting unit at the University of California at Davis in Sacramento who is in charge of physician billing for the hospitals six neurosurgeons, In addition to detailed operative notes, HCFA requires the documentation of the following:

1. Pain Control. For opioid drugs (e.g., morphine) administered, document that the treatment is for severe, chronic intractable pain of malignant or nonmalignant origin for patients with a life expectancy of at least three months who have proven unresponsive to less invasive medical therapy by including the following:

Specific indication in the patients history that he or she has not responded to noninvasive methods of pain control such as a systemic opioid (including attempts to eliminate physical and behavioral abnormalities that may cause an exaggerated reaction to pain).

A record of a preliminary trial of intraspinal opioid drug administration with a temporary intrathecal/epidural catheter to substantiate acceptable pain relief and degree of side effects (including effects on the activities of daily living) and patient acceptance.

2. Spasticity treatment. For administration of antispasmodic drugs (e.g., baclofen) document evidence that the patient was unresponsive to less invasive medical therapy by including:

Notation of a trial period of at least six weeks during which it is proven that the patient cannot be maintained on noninvasive methods of spasm control such as oral antispasmodic drugs because these methods either failed to control the spasticity or produced intolerable side effects.

Commentary that prior to pump implantation, the patient responded favorably to a trial intrathecal dose of the antispasmodic drug.

Note: Occasionally, the surgeon will implant just the catheter in order to carry out this trial. If the pump is then implanted after a successful trial, the placement may be considered a prospectively planned staged procedure, and can be billed with the -58 modifier.

Procedure and Modifier Coding Tips

Neurosurgical coders most often face potential denials or lost revenue due to incorrect procedural coding in four key areas:

1. Implantation of catheter and pump. Coding 62362 (implantation or replacement of device for intrathecal or epidural drug infusion) and 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) appended with -51(multiple procedures) is recommended by Beverly Trout, coding and reimbursement specialist for Associated University Neurosurgeons in Peoria, Ill.,because although the catheter and the pump are implanted at the same time, 62362 has the higher RVU and should be billed first.

2. Modifier -78. If the pump is implanted to control pain in the wake of a surgical procedure within the 90-day global period, modifier -78 (return to the operating room for a related procedure during the postoperative period) should be appended to 62362 and 62350 (in addition to modifier -51) to show the relationship between the initial surgery, the implantation, and any other charges related to the surgery during that time frame, says 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

3. Refilling, maintenance and reprogramming. When the patient returns to the office for the refilling/ maintenance (96530) and possible reprogramming of the pump (62368), the physician or the nurse should dictate a report detailing the amount of the drug used and all that occurred during the procedure. We have found that we get better results from insurance companies when we send a copy of that days dictation with the billing, Trout says.

4. Flushing ports and refilling. The accessing and flushing of the implanted infusion pump and its attached catheter is usually performed by a nurse under physician supervision and billed as 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician). 99211 must be billed under incident-to guidelines, which state:

A) the neurosurgeon needs to be on-site at the time of the treatment;
B) the patients first visit must have been with the neurosurgeon; and
C) the neurosurgeon sees the patient for any new medical problems.

The documentation needs to include the date of service, vital signs (if taken), service provided, and the signature of the nurse. Code 99211 can only be billed if the nurse is the only healthcare practitioner seeing the patient.

If the refilling/maintenance of the pump and the flushing of the ports are performed on the same day, practices should bill 96530 (refilling and maintenance of implantable pump or reservoir) because of the maintenance service provided.

Reimbursement for the Pain Pump and Catheter

Trout says that as long as the neurosurgeons office supplies the pump and the catheter, they can seek reimbursement from their durable medical equipment regional carrier (DMERC) once they have been implanted. For further information on these carriers, or to apply for a DME number (necessary for billing), please visit the following Web sites:

Region A (Northeast): www.uhc.com
Region B (Midwest): awww.astar-federal.com/anthem/affiliates/administar/dmerc
Region C (South): www.pgba.com
Region D (West): www.cignamedicare.com/dmerc

The choice of HCPCS code to bill your DMERC depends on the kind of pump and catheter implanted:

E0782 infusion pump, implantable, nonprogrammable

E0783 programmable (includes all components, e.g., pump, catheter, connectors, etc.)

E0785 implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement

E0786 implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)

Note: If the hospital where the surgery was performed supplied the pump, the neurosurgeon cannot bill for it.

Billing for Medication

Neurosurgeons using the J (drug) codes from the HCPCS manual when billing for the pain pump medications should keep in mind that choosing the correct code depends not only on the drug but also on the amount needed for refilling, Trout says. For example, if the pump is partially refilled with morphine, J2270 (injection, morphine sulfate, up to 10 mg) might be used.