Orthopedic Coding Alert

You can usually collect for spinal pain pump insertions, but most other pain pumps bundle into main procedure

Whether you're billing 37202, 11981 or an unlisted-procedure code, you're billing improperly for pain pump insertion following non-spinal orthopedic surgeries. That's because the American Academy of Orthopaedic Surgeons considers the pain pump insertion a component of the major procedure that the surgeon performs. Therefore, you should not report the insertion separately.

The procedure: Orthopedic surgeons will implant a catheter directly into a patient's surgical site to deliver postoperative pain medication, says Bill Mallon, MD, medical director at Triangle Orthopaedic Associates in Durham, N.C., and a pioneer in creating the implantable postsurgical pain pump.

"We started using them on shoulder surgeries, but the knee surgeons then began extending their use to ACL procedures," Mallon says. The surgeons usually remove the pain pumps after 48-72 hours.
 
Code the Pump as You'd Code a Drain: Not at All

Wrong way: Coders tell us that they report either a site-specific unlisted-procedure code (such as 23929, Unlisted procedure, shoulder), 11981 (Insertion, non-biodegradable drug delivery implant) or even the cardiovascular code 37202 (Transcatheter therapy, infusion other than for thrombolysis, any type [e.g., spasmolytic, vasoconstrictive]) for surgical pain pump insertion. But whether or not your practice collects for these codes, you should not bill them when the surgeon implants a postsurgical pain pump.

Right way: You should include the surgeon's work implanting the pump in the global fee for the main surgery. "We are never allowed to code drain placement at the end of a procedure," Mallon says. "Pain pump placement is simply placing a drain, but in this case, instead of draining anything, local anesthetics are injected. But the difficulty is the same as a drain."

Mallon estimates that the pain pump placement takes about 10 seconds. "I have never tried to code for it, and if I worked at an insurance company, I'd deny it every time," he says.

Even if Insurer Pays for Insertion, Don't Bill It

Pitfall: Some coders report that insurers have reimbursed them for pain pump insertions when they bill an unlisted-procedure code. However, just because the insurer pays you for a procedure doesn't mean you're coding correctly. If the insurer reviews your records and determines that you have improperly billed for pain pump insertion, you will likely be in hot water.

Most insurers' computer programs screen claims for pain pump insertion and deny the service if the practice bills the insertion with a surgical procedure, and "rightly so," says Chris Felthauser, CPC, CPC-H, a PMCC-approved medical coding instructor with Orion Medical Services.

In black and white: CIGNA, a Part B Medicare carrier in Idaho, North Carolina and Tennessee, publishes a policy that states that surgical wound catheters for postoperative pain control are now "being used in a wide variety of surgeries ... No existing codes apply to this service, and CPT codes such as 11981 or codes from the 64400-64449 series cannot be used for this service."

CIGNA's policy also reminds coders that "Leaving a catheter behind in the operative field is considered a component of the surgical procedure and not separately payable by Medicare. It is important to also note that the control of pain is generally included in the global surgical package as part of postoperative care."

What about pump removal? Again, this procedure is similar to drain removal, Mallon says. "It should be part of the global package.

The upside: "The facility may be able to bill for the actual pump itself," Felthauser says. "Check your contracts to see if it is reimbursable. We have negotiated this item into most of our contracts."
 
Pump Insertion at Spinal Cord Is Payable

In most cases, you can still collect payment when the surgeon implants a pain pump at the patient's spine for chronic pain conditions. Insurers evaluate such pain pump implantations against very stringent guidelines, but they often cover the service for conditions such as failed back syndrome or arthritis.

Explanation: The spine procedure "is far more delicate surgery than the extremity pump insertion and often requires a separate procedure simply to insert the pump," Mallon says.

Insurers often require documentation that demonstrates your surgeon's prior attempts to alleviate the patient's pain and proof of the patient's loss of ability before they will pay you for spinal pain pump implantation. If your patient meets the insurers' guidelines, you should report one of the following codes for implanting the spinal pain pump: