Ambulatory Surgery Center Coding and Payment Guide 2015

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1 Targeted Drug Delivery Ambulatory Surgery Center Coding and Payment Guide 2015 Flowonix Medical has compiled this coding information for your convenience. This information is gathered from third party sources and is subject to change without notice. This information is presented for descriptive purposes only and does not constitute reimbursement or advice. It is always the provider s responsibility to determine medical necessity and submit appropriate codes, modifiers, and charges for services rendered. Please contact your local carrier/payer for interpretation of coding and coverage. Flowonix Medical does not promote the use of its products outside their FDA approved labeling. The Customer Care Support Program is available to answer any of your coding and billing inquiries at ICD-9-CM Diagnosis Code Options Diagnosis codes are used by both physicians and facilities to document the indication for the procedure. Intrathecal drug delivery is directed at managing chronic, intractable pain. Pain can be coded and sequenced several ways depending on the documentation and the nature of the encounter. Regardless of the place of service, ICD-9-CM diagnosis codes do not change. Codes from the 338 series can be used as the principal diagnosis when the encounter is for pain control or pain management, rather than for management of the underlying conditions. Additional codes may then be assigned to give more detail about the nature and location of the pain and the underlying cause. When a specific pain disorder is not documented or the encounter is to manage the cause of the pain, the underlying condition is coded and sequenced as the principal diagnosis. Disclaimer: It is always the provider s responsibility to determine medical necessity and submit appropriate codes, modifiers and charges for services rendered. Please contact your local carrier/payer for interpretation of coding, coverage and payment. Flowonix Medical does not promote the use of it s products outside their FDA approved labeling. Page 1 of 7 PL

2 The table below gives a breakdown of commonly billed ICD-9-CM diagnosis codes used in all settings. Category Code Code Description Chronic Pain Disorders Reflex Sympathetic Dystrophy and Causalgia 2 Underlying Causes of Chronic Non-Cancer Pain Underlying Causes of Cancer Pain and 733.0X , , , , , , , , plus or Central Pain Syndrome Other Chronic Pain Neoplasm-related pain Chronic Pain Syndrome Reflex sympathetic dystrophy of the lower limb (CRPS Type I) Causalgia of the lower limb (CRPS Type II) Postherpetic neuralgia Arachnoiditis, chronic Arachnoiditis, other and unspecified Phantom limb syndrome Peripheral neuropathy of lower limb Radiculitis due to herniated disc, lumbar Radiculitis due to degenerative disc disease, lumbar Postlaminectomy syndrome, lumbar region (failed back syndrome) Radicular syndrome of lower limbs Collapsed vertebra due to osteoporosis Esophageal Cancer Stomach Cancer Colon and rectal Cancer Liver Cancer Pancreatic Cancer Lung Cancer Bone Cancer Breast Cancer Cervical Cancer Uterine Cancer Ovarian Cancer Prostate Cancer Testicular Cancer Bladder Cancer Kidney Cancer Brain and Spinal Cord Cancer Pathological fracture due to bone cancer Attention to Device V Fitting and adjustment of devices related to nervous system Page 2 of 7

3 ICD-9-CM diagnosis codes used in all settings (continued) 1 Pain must be specifically documented as chronic to use code Similarly the diagnostic term chronic pain syndrome must be specifically documented to use code If these terms are not documented, then other symptom codes for pain may be assigned instead. However, they cannot be sequenced as a principal diagnosis. Rather, the underlying condition would ordinarily be used as the principal diagnosis in this circumstance. 2 CRPS not specified by type defaults to type 1. Codes from the 338 series should not be assigned with CRPS as pain is a known component of these disorders. 3 V53.09 is used as the principal diagnosis when patients are seen for routine device replacement and maintenance. A secondary diagnosis code is then used for the underlying condition. HCPCS II Device and Drug Codes Commonly billed HCPCS II Device and Drug Codes used in all settings. However, in the outpatient hospital setting these codes are used in conjunction with Device C codes when billing Medicare. Device/Drug Code Code Description Programmable Pump and Catheter Programmable Pump Only (Replacement) Intraspinal Implantable Catheter Only Infumorph (preservativefree morphine sulfate sterile solution) 4 Anesthetic Drug Administered Through IV E0783 E0786 E0785 J2274 J7799 Infusion pump system, implantable, programmable (includes all components) Implantable programmable infusion pump, replacement, does not include implantable catheter. Implantable intraspinal catheter used with implantable infusion pump, replacement Injection, morphine sulfate, perservative-free for epidural or intrathecal use, 10 mg NOC drugs, other than inhalation drugs, administered through DME Refill Kit A4220 Refill Kit for implantable infusion pump 4 Permanent code J2274 is effective January 1, Previous temporary code Q9974 (effective July 1, 2014 through December 31, 2014) and previous permanent code J2275 (effective through June 30, 2014) have been deleted. Page 3 of 7

4 Ambulatory Surgery Centers All ASC s utilize ICD-9-CM diagnosis codes, CPT procedural codes, and HCPCS II Device and Drug Codes. Unlike the outpatient hospital setting C-Codes do not need to be associated with CPT codes when billing Medicare. It is important to remember that Medicare has special rules and a separate payment system in ASCs regarding reimbursement for devices and drugs. Under Medicare s ASC payment system, ASCs usually should not assign or report HCPCS II codes for devices and drugs on claims sent to Medicare Medicare generally does not make a separate payment for devices and drugs in the ASC. Instead, payment is packaged into the payment for the ASC procedure. ASCs are instructed not to bill HCPCS II codes to Medicare for devices and drugs that are packaged. Of the devices and drugs, only Prialt is not packaged. For this reason, Prialt should be coded separately but none of the other drugs and devices should. At this time, the Prometra pump is not labeled for the use of any drug except Infumorph. ASCs should report all charges incurred. However, only charges for non-packaged items should be billed as separate line items. For example, the ASC should report its charge for the implantable infusion pump. However, because the pump is a packaged item it should not be reported on its own line. Instead the ASC should bill a single line for the implantation procedure with a single charge, including not only the charge associated with the operating room but also the charges for the pump, catheter, morphine, and all other packages items. ASC Coding and Payment CPT Procedure Codes Medicare payment for procedures performed in an ambulatory surgery center is based on Medicare s ambulatory patient classification methodology for hospital outpatient payment. Each CPT code designated as a covered procedure in an ASC is assigned the same relative weight, or a comparable weight, as under the hospital outpatient APC system. This is then converted to a flat payment amount using a conversion factor unique to ASCs. Multiple procedures can be paid for each claim. Certain ancillary services, such as imaging, are also covered when they are integral to covered surgical procedures, although they may not be separately payable. In general, there is no separate payment for devices; their payment is packaged into the payment for the procedure. Also, when multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedure and 50% of the rate for the second and all subsequent procedures. Page 4 of 7

5 ASC Coding and Payment CPT Procedure Codes (continued) Procedure Code 5 Code Description 5 Payment Indicator 6,7,8 Multiple Procedure Discount Medicare National Average 6,8, Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) A2 Yes $368 Trial 11,12, Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) A2 Yes $368 Implantation or Revision, of Catheter Implantation or Replacement of Pump 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 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming A2 Yes $2,007 J8 No $13,241 ASC Payment Indicator A2 = ASC payment based on OPPS relative payment weight J8 = Device intensive procedure; paid at adjusted rate N1 = Packaged service/item; no separate payment made Page 5 of 7

6 ASC Coding and Payment CPT Procedure Codes (continued) Procedure Code 5 Code Description 5 Payment Indicator 6,7,8 Multiple Procedure Discount Medicare National Average 6,8,10 Removal of Catheter or Pump Removal of previously implanted intrathecal or epidural catheter Removal of subcutaneous reservoir or pump previously implanted for intrathecal or epidural infusion A2 No $806 A2 No $1,615 Drug 15 J2274 Injection, morphine sulfate, preservativefree for epidural or intrathecal use, 10 mg N1 N/A N/A Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation or reservoir status, alarm status, drug prescription status); without reprogramming or refill P3 No $23 Analysis/ Reprogramming 16, Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation or reservoir status, alarm status, drug prescription status); with reprogramming P3 No $ Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation or reservoir status, alarm status, drug prescription status); with reprogramming or refill P3 No $96 ASC Payment Indicator A2 = ASC payment based on OPPS relative payment weight J8 = Device intensive procedure; paid at adjusted rate N1 = Packaged service/item; no separate payment made Page 6 of 7

7 ASC Coding and Payment CPT Procedure Codes (continued) 5 CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/ DFARS restrictions apply to government use. 6 Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg https://federalregister.gov/a/ Published November 10, Accessed November 11, The Payment Indicator shows how a code is handled for payment purposes. A2 = surgical procedure, payment based on hospital outpatient rate adjusted for ASC; J8 = device-intensive procedure, payment amount adjusted to incorporate device cost; K2 = drugs paid separately when provided integral to a surgical procedure on ASC list, payment based on hospital outpatient rate; N1 = packaged service, no separate payment; P3 = office-based procedure, payment based on physician fee schedule. 8 Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2015 ASC conversion factor is $ The conversion factor of $ assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 79 Fed Reg https:// federalregister.gov/a/ Published November 10, Accessed November 11, Payment is adjusted by the wage index for each ASC s specific geographic locality, so payment will vary from the stated national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. 9 When multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedures and 50% of the rate for the second and all subsequent procedures. These procedures are marked Y. However, procedures marked N are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with other procedures. 10 For Medicare billing, ASCs use a CMS-1500 form. 11 According to CPT manual instructions, injection codes and both include temporary catheter placement. Code is used for needle injection or when a catheter is placed to administer one or more injections on a single calendar day. Code is used when the catheter is left in place to deliver the agent continuously or intermittently for more than a single calendar day. 12 Although CPT manual instructions allow code for fluoroscopic guidance to be coded separately with injection codes and 62319, CMS has published that separately coding is prohibited. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2015 Final Rule; 79 Fed Reg https://federalregister.gov/a/ Published November 13, Accessed November 13, Check with the payer for specific guidelines on coding a tunneled trial catheter. Options may include to reflect the temporary nature of the trial or to reflect the tunneling even though the code definition specifies long-term. 14 For pump or catheter replacement, National Correct Coding Initiative (NCCI) edits do not allow removal of the existing device to be coded separately with implantation of the new device. 15 Code J2274 is packaged and not separately payable. For 2015, the payment amount is based on ASP plus 6%. (Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Pro- spective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule. 79 Fed. Reg , https://federalregister.gov/a/ Published November 10, Accessed November 11, 2014). ASP values are publicly available at index.html. CMS updates Average Sales Price (ASP) drug pricing on a quarterly basis. 16 Use the Analysis/Reprogramming codes only for follow-up services. NCCI edits do not allow these codes to be assigned at the time of pump implantation. 17 Code is used for pump interrogation only (e.g., determining the current programming, assessing the device s functions such as battery voltage and settngs, and retrieving or downloading stored data for review). Code is used when the pump is both interrogated and reprogrammed. Code is used when the pump is interrogated, reprogrammed and refilled by facility ancillary staff, eg nurse. Page 7 of 7

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