Neurosurgery Coding Alert

If you fail to show that a patient hasn't responded to less invasive treatments, chances are your pain pump-related services - including implantation and ongoing maintenance - will face immediate denial. Stressing medical necessity and demonstrating that you have met payer requirements will go a long way toward ensuring the claim success, coding experts say.

Chronic Pain and Spasticity May Call for Pain Pumps

Certain drugs may control symptoms such as chronic pain or spasticity when administered directly into the intrathecal or epidural space, says Francis Lagattuta, MD, chairman of the CPT nonoperative coding committee for the North American Spine Society and a board member of the American Association of Electrodiagnostic Medicine.
 
Patients requiring a drug infusion pump typically present with a variety of chronic symptoms. The patient's specific pain management needs determine the type of drug necessary for treatment. For instance, the surgeon may choose a morphine pump for a patient with nerve damage, while a baclofen pump is more appropriate for spasticity.
 
As an example, a patient undergoes an extensive spine surgery and has 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.

Patient History Must Demonstrate Responsiveness

Payers will not approve pain pumps for just any patient. Rather, the medical record must demonstrate two important circumstances, according to Medicare and private- payer guidelines:

 1. The patient history indicates failure to respond satisfactorily to less invasive methods.
 2. The physician performed and documented a preliminary trial of neuraxial drug administration to demonstrate symptom relief, side effects and patient acceptance of therapy.

Guidelines also stipulate that any patient eligible for a pain pump must have a life expectancy of at least three months. And, the payer will not cover pain pumps for patients with known allergy or hypersensitivity to the drug being used (for example, oral baclofen, morphine, etc.), those with an infection, or those whose body size is insufficient to support the device.
 
The details of meeting the first of the above requirements depend on the condition the surgeon hopes to treat using the pain pump. For spasticity, the surgeon must demonstrate that he cannot maintain the patient on noninvasive methods of spasm control, such as oral antispasmodic drugs, over at least a six-week trial because these methods either fail to control adequately the spasticity or produce intolerable side effects, says Rhonda Petruziello, CPC, reimbursement specialist for neurosurgery at Cleveland Clinic Foundation in Cleveland.
 
For intractable pain, on the other hand, the patient's history must indicate that he would not respond adequately to noninvasive pain-control methods, such as systemic opioids (including attempts to eliminate physical and behavioral abnormalities that may cause an exaggerated response to pain).

Payers Allow for a Variety of Diagnoses

A survey of payer guidelines shows that they will allow for a variety of indications (signs, symptoms and conditions) to demonstrate medical necessity for pain pumps. These include control of spasticity caused by spinal cord disease, spinal cord injury or multiple sclerosis; for chronic persistent pain of malignant origin (such as cancers); and for chronic persistent pain secondary to nonmalignant causes such as severe vertebral compression fractures, spinal stenosis, postherpetic neuralgia, failed back syndrome (lumbar, thoracic or cervical), radiculitis (lumbar, thoracic or cervical), cerebral palsy, and spinal cord injury, among others.
 
For chronic persistent pain secondary to non-malignant causes, you must include documentation from the patient's medical record that indicates one of the following, according to several payers' local medical review policies (LMRP):