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Neurosurgery Coding Alert

Pump Up Reimbursement:

Prove Necessity to Get Pain Pump Claims Paid

Published on Mon Jul 01, 2002

Although pain pumps can alleviate a patient's postsurgical discomfort, some insurers consider them a "last-ditch" treatment to be used only after other pain-control methods have failed.

To meet stringent payer requirements and be reimbursed for implanting and maintaining a pain pump, neurosurgeons must not only supply the proper CPT codes but also carefully document medical necessity and patient history.

Surgical Implantation

A pain pump consists of several parts, three of which the pump itself, a catheter and an access port are surgically implanted under the patient's skin. The pump is a metal disk about an inch thick and three inches around, which stores and releases medication to treat chronic pain via the catheter to the prescribed location. The access port allows the physician to bypass the pump and access the catheter directly to administer medications or sterile solutions.

Implantation of the pump and catheter are reported separately, says Kee D. Kim, MD, associate professor of neurosurgery at University of California, Davis in Sacramento. Catheter placement is coded either 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) or 62351 ( with laminectomy) as appropriate. Depending on the type of pump, surgical implantation is reported using one of three codes. A programmable pump (described above) is coded 62362 (Implantation or placement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming). A non-programmable pump is coded 62361, while a simple subcutaneous reservoir is reported using 62360.

Because the pump and catheter are implanted during the same operative session, modifier -51 (Multiple procedures) should be appended to the lesser-paying procedure, Kim says.

Note: Depending on the circumstances, either the catheter or pump placement may be the higher-paying procedure. The relative value units (RVUs) for each procedure are: 62350, 11.2 RVUs; 62351, 18.28 RVUs; 62360, 4.78 RVUs; 62361, 9.3 RVUs; 62362, 11.91 RVUs.

And, if the pump and catheter are implanted during the 90-day global period of a previous surgery (as is often the case), both procedures should be reported with modifier -78 (Return to the operating room for a related procedure during the postoperative period) appended.

Note: For more information on modifier -78 and related modifiers -58 (Staged or related procedure or service by the same physician during the postoperative period) and -79 (Unrelated procedure or service by the same physician during the postoperative period) see Neurosurgery Coding Alert, November 2001.

Supplying the Evidence:Spasticity

Prior to placing a pain pump, the surgeon must prove medical necessity and demonstrate that the patient meets payer-mandated criteria. Generally, Kim explains, neurosurgeons will place a pump for one of two reasons: to treat severe spasticity or, more commonly, intractable pain.

According to Nationwide Medicare local medical review policy (LMRP) DEV-001, covering Ohio and West Virginia, an implantable pump is covered to administer antispasmodic drugs (e.g., baclofen) to treat chronic intractable spasticity in patients who have proven unresponsive to less invasive medical therapy, as determined by the following:


  • Over at least a six-week trial, the patient cannot be maintained on noninvasive methods of spasm control, such as oral antispasmodic drugs, because these methods either fail to control adequately the spasticity or produce intolerable side effects; and
  • Prior to pump implantation, the patient must have responded favorably to a trial intrathecal dose of the antispasmodic drug.

    The claim must indicate that the patient's spasms have not responded to noninvasive therapy, but there was a satisfactory response to the trial of intrathecal therapy (e.g., "six-week oral drug trial failed to relieve symptoms; intrathecal trial successful"). The patient's medical record must be able to confirm that all of the above criteria for coverage have been met.

    Furthermore, the LMRP DEV-001 specifies that the following diagnoses may provide medical necessity:

    340 Multiple sclerosis
    342.10-342.12 Spastic hemiplegia
    343.0-343.9 Cerebral palsy
    344.00-344.09 Quadriplegia
    344.1 Paraplegia
    781.0 Involuntary muscle spasms
    806.00-806.9 and 952.00-952.9 Spinal cord injury.

    Supplying the Evidence:Intractable Pain

    CMS and local-payer policy specify that for treatment of severe, chronic, intractable pain of malignant or nonmalignant origin, an implantable pump is covered when used to administer opioid drugs (e.g., morphine) intrathecally or epidurally. The patient must have a life expectancy of at least three months and have proven unresponsive to less invasive medical therapy, as determined by the following:

  • The patient's history must indicate that he or she would not respond adequately to noninvasive methods of pain control, such as systemic opioids (including attempts to eliminate physical and behavioral abnormalities that may cause an exaggerated response to pain); and

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

    Note: Occasionally, the surgeon will implant a catheter to carry out the preliminary trials discussed above. If the pump is implanted following a successful trial, append modifier -58 to the applicable CPT code to indicate that the procedure was staged and planned prospectively.

    Once again, documentation must provide evidence that the patient did not responded to noninvasive therapy, but did respond to a trial of intrathecal therapy. Applicable diagnoses include:

    053.12-053.13 Postherpetic neuralgia
    141.0-171.9 and 174.0-208.91 Primary cancers
    197.0-199.1 Metastatic cancer
    337.20-337.29 Reflex sympathetic dystrophy
    353.6 Phantom limb pain
    354.4 and 355.71 Causalgia.

    Most payers will provide individual consideration for other conditions associated with chronic intractable pain (e.g., failed back syndrome, chronic pain secondary to extensive soft tissue or skeletal injuries, arthritis or severe neuropathies), says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. According to Nationwide Medicare LMRP DEV-001, "In these cases, claims must be accompanied by documentation from the patient's medical record which indicates one of the following:

    1. Prior therapies (specifically identified) have not alleviated the pain
    2. A significant loss of ability to function independently has resulted from the pain
    3. Prior interventions included a multi-disciplinary evaluation and treatment program which addressed physical, psychological and behavioral components of the pain without success."

    In all cases, a pain pump will not be covered for patients with known allergy or hypersensitivity to the drug being used (e.g., oral baclofen, morphine, etc.), those with an infection, or those whose body size is insufficient to support the weight and bulk of the device.

    Refilling,Maintenance and Removal/Replacement

    When coverage is allowed for an implanted pump, the required refilling and maintenance of the pump are also covered, Sandham explains. The pump is refilled via a self-sealing, rubber septum on the body of the pump. A needle is inserted through the skin and through the septum to replenish the drug supply. For this service, report 96530 (Refilling and maintenance of implantable pump or reservoir), along with the applicable HCPCS J code for the drug itself. Report reprogramming (to adjust dosage) using 62368 (Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion [including evaluation of reservoir status, alarm status, drug prescription status]; with reprogramming). Electronic analysis of the pump without reprogramming is reported using 62367.

    Flushing of the pump and catheter is included in any E/M service provided (e.g., a 99211-99215) and should be considered when arriving at a level of service. Generally, a nurse, under the supervision of the physician, will flush the equipment if the patient presents solely for this purpose. In this case, report 99211 (Office or other outpatient visit for the evaluation and management of an established patient). Under "incident to" guidelines, the physician must be on-site during the procedure and must see the patient if any new medical problems have developed, Sandham says.

    If the pump and/or catheter must be removed, report 62365 (Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion) and 62355 (Removal of previously implanted intrathecal or epidural catheter), as appropriate. If both the pump and reservoir are removed during the same operative session, append modifier -51 to 62355. Subsequent revisions or replacement of these components should be reported using the placement/revision codes 62350-62362.

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