Physician Coding and Payment Guide 2015

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1 Targeted Drug Delivery Physician 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 6 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 6

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 6

4 Physician Coding and Payment Physician Office Medicare varies specific reimbursement from the national average based on the geographical area in which the services are rendered, for this reason, national averages are shown, but each specific payment to physicians will vary by geography. Also note that any applicable coinsurance, deductible and other amounts that are patient obligations are included in the national average payment shown. Different amounts are paid depending on the place of service in which the physician rendered the services. Facility includes physician services rendered in hospitals and ASCs. Physician payments are generally lower in the facility setting because the facility is incurring the cost of some of the supplies and other materials. Physician payments are generally higher in the office setting because the physician incurs all costs there. CPT Procedure Codes 2015 Medicare National Average 5 Procedure Code Code Description Physician Office Facility 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) $225 $92 Trial 6, 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) $170 $99 Implantation or Revision of Catheter 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, revision, or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion/pump; with laminectomy N/A $401 N/A $899 Page 4 of 6

5 CPT Procedure Codes (continued) 2015 Medicare National Average 5 Procedure Code Code Description Physician Office Facility Implantation, or Replacement of Pump Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming N/A $415 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 N/A $280 N/A $309 Fluoroscopy for Catheter Placement and Injection or Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) $86 $86 Drug 8 J2274 Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg ASP+6% prescription status); without reprogramming or refill $41 $26 Refill/Analysis/ Reprogramming prescription status); with reprogramming $57 $ $123 prescription status); with reprogramming and refill 10 Page 5 of 6

6 CPT Procedure Codes (continued) 2015 Medicare National Average 5 Procedure Code Code Description Physician Office Facility prescription status); with reprogramming and refill (requiring skill of a physician or other qualified health care professional) 10 $129 $48 Refill/Analysis/ Reprogramming Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed $ Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care professional $122 $40 Catheter Dye Study Puncture of shunt tubing or reservoir for aspiration or injection procedure N/A $60 Evaluation and Management Office or other outpatient visit $20 - $146 $9 - $112 5 Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2015 is $ through March 31, 2015 in accordance with the CMS-1612-FC, Center for Medicare & Medicaid Services PFS Relative Value File (January release) Published December 30, Note: Any applicable coinsurance, deductible and other amounts that are Patient Obligations are included in the payment amount shown. Also, final physician payment is adjusted by the Geographic Practice Cost Indices (GPCI). 6 Per the CPT Manual, CPT code is used for needle injection or when a catheter is placed to administer one or more injections on a single calendar day. CPT code is used when the catheter is left in place to deliver the agent continuously or intermittently for more than a single calendar day. Both CPT codes (62311 and 62319) include temporary catheter placement. 7 CMS has published that reporting CPT code is prohibited because and are already valued to include fluoroscopic guidance. Center of Medicare and 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 Published November 13, Reimbursement for intrathecal drugs vary considerably based on State specific provider guidelines. 9 The Refill/Analysis & Reprogramming codes are only used for follow-up services-these codes are not to be used at the time of implantation. 10 Code is assigned when the pump is interrogated, reprogrammed and refilled by ancillary staff, eg: nurse under physician supervision in the office. As defined for 2014, code is used when the pump is interrogated, reprogrammed, and refilled by a physician or other qualified health care professional. The AMA defines other qualified health care professional as an individual who performs professional services within the scope of practice and is able to bill their services independently, eg. nurse practitioner. However, because payer interpretations for use of code may vary, check with the individual payer on the types of practitioners who may assign and bill vs CPT copyright 2014 American Medical Association. All rights reserved. CPT codes and descriptions only are copyright 2014 American Medical Association. All rights reserved. No fee schedules are included in CPT. The American Medical Association assumes no liability for data contained or not contained herein Federal Register / Vol. 79, No. 237 / November 13, Note: The payment amounts indicated are based upon data elements published in the Federal Register dated 11/13/2014, and subsequent legislation and updates issued by CMS. These changes are effective for services provided from 1/1/15 through 12/31/15. CMS may make adjustments to any or all of the data inputs from time to time. All CPT codes are copyright AMA. Page 6 of 6

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