Oncology & Hematology Coding Alert

Pain management has garnered increased attention recently. End-of-life care advocates have long criticized physicians, including oncologists, for not providing proper palliative care to their patients. This sentiment has been underscored by recent lawsuits for inadequate pain management, including a case involving an 85-year-old cancer patient.

With the growing concern over the quality of pain management, physicians are trying to catch up on the latest in palliative care, and many are still confused about how to get reimbursed for their pain management services. Nevertheless, they can be rightfully reimbursed if they attend to the details, such as validating medical necessity if they used an off-label drug, using the correct codes for the type of drug delivery system used and so forth.

Drug Choice and Reimbursement

Choosing the appropriate drug is also a challenge for many physicians. Basic pain-management drugs come in two forms: non-steroidal anti-inflammatory drugs, such as ibuprofen and aspirin; and opioids, such as morphine, fentanyl or codeine. In most cases, pain drugs are given orally. The remainder are administered intramuscular, subcutaneously, intravenously, intraspinal or intraventricular.

Medicare regulations mention common drugs, such as morphine, that can be used with infusion pumps for intractable pain. But the population of pain-management drugs is much greater, says Terry Gutgsell, MD, medical director of the Hospice of the Bluegrass in Lexington, Ky.

Some of the available drugs have primary uses outside palliative care, such as methadone (used to treat heroin addiction), J1230; ketamine (anesthesia); and pamidronate (bone resorption in metastatic breast cancer), J2430. These drugs are effective, but physicians have the burden of proving medical necessity, Gutgsell says. (This is especially important for expensive drugs like pamidronate, which can cost $600 to $1,200 for a single injection.)

Gutgsell advises physicians who plan to use an off-label drug to provide data published in journals and, when seeking advice from pain-management experts, to ask for published data to support the recommendation. Also, Laurie Lamar, RHIA, CCS, CTR, CSS-P, reimbursement specialist with the American Society of Clinical Oncology in Alexandria, Va., recommends following Medicare regulations for off-label use of drugs and biologicals. Oncologists can expect off-label drugs to be covered if all of the following criteria are met:

the drug meets the definition of drugs and biologicals;
the drug is the type that cannot be self-administered;
the drug meets all the general requirement for coverage of items as incident to a physicians services;
the drugs are reasonable and necessary for the diagnosis or treatment of the illness or injury for which they are administered according to accepted standards of medical practice;
the drugs are not excluded as immunizations;
the drug has not been determined by the FDA to be less than effective.

Injection Coding

In the rare instance that a physician administers pain- management drugs in the office or if drugs are administered in a hospital or outpatient facility, the physician can also bill for related procedures, such as injections. Other than the cost of the drugs themselves, drugs that are self-administered are not covered by Medicare; however, drugs that are administered in the physicians office via injection or infusion pump have a variety of reimbursement codes associated with them, according to Lamar.

Coding for pain management is a little more straightforward since the AMA published CPT 2000. There was so much confusion involved with reporting pain-management procedures that the American Medical Association (AMA) made massive changes to CPT 2000 in hopes of clarifying the coding of injection, drainage, and aspiration procedures performed in pain management, says Laurie Castillo, MA, CPC, CPC-H, president of the American Association of Procedural Coders Northern Virginia Chapter and consultant at Physician Coding & Compliance Consulting, both in Manassas, Va. In many cases, one code replaced several; among many examples, 62310 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance(s) [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) replaced four old 1999 codes: 62274, 62275, 62288 and 62298.

Pain Pump Billing

For IV and intraspinal administration, an infusion pump is used. (E0779-E0791, infusion supplies). Physicians can expect to be reimbursed for using an implantable infusion pump (E0782-E0785), if it is used to administer opioid drugs (e.g., morphine) intrathecally or epidurally (64999) for treatment of severe chronic intractable pain of malignant or nonmalignant origin in patients who have a life expectancy of at least three months and who have proven unresponsive to less invasive medical therapy, if the following criteria are met:

The patients history must indicate that he/she would not
respond adequately to non-invasive methods or pain control, such as systemic opioids (including attempts to eliminate physical and behavioral abnormalities that may cause an exaggerated reaction to pain);
A preliminary trial of intraspinal opioid drug
administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate adequately
acceptable pain relief and degree of side effects
(including effects on the activities of daily living) and
patient acceptance.

A physician can expect reimbursement for a patients use of an infusion pump only if the physicians office owns the pump. In that case, the practice can bill its durable medical equipment regional carrier using its provider number. If it rents the pump from a vendor, the vendor is responsible for billing Medicare.

In addition to billing for pump rental, oncologists have several other reimbursement opportunities connected with pain pumps. The insertion of a catheter and implantation of a pump are covered by Medicare. Catheter and pump implantation codes includes:

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;
62351 with laminectomy;
62355 removal of previously implanted intrathecal or epidural catheter;
62360 implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous
reservoir;
62361 non-programmable pump;
62362 programmable pump, including preparation of pump, with or without programming.

Codes 96520 (refilling and maintenance of portable pump) and 96530 (refilling and maintenance of implantable pump or reservoir) can be used, but should not be used to report port flushing.

Care Plan Oversight and Reimbursement

Unfortunately, cancer often results in a terminal diagnosis. For many of the terminal patients hospice is an appropriate setting for their care, including pain management. Nevertheless, the treating physician maintains oversight of the patient, working with hospice professionals and medical directors. The physician who manages patient pain in a hospice setting can bill for care plan oversight services, 99377-93778, each month.

For example, if a physician has to adjust pain medication for his or her patient and communicates the changes to hospice staff, the physician can bill 99377 if the oversight service lasts less than 30 minutes, 99378 if the service is more than 30 minutes.

The oversight service does not have to be continuous, Lamar says. The billed time can be accumulated over a one-month period and it does not have to be face-to-face time as long as the physician has had at least one face-to-face contact within six months of the time the service is billed.