Physician Coding and Payment Guide 2015

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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 855-356-9666.

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

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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

338.0 338.291

338.3 338.4

Central Pain Syndrome Other Chronic Pain Neoplasm-related pain Chronic Pain Syndrome

Reflex Sympathetic Dystrophy and Causalgia2

337.22 355.71

Reflex sympathetic dystrophy of the lower limb (CRPS Type I)

Causalgia of the lower limb (CRPS Type II)

Underlying Causes of Chronic Non-Cancer Pain

053.12-053.13 322.2 322.9 353.6 355.8 722.10 722.52 722.83 724.4 733.13 and 733.0X 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

Underlying Causes of Cancer Pain 150.0-150.9 151.0-151.9 153.0-154.8, 197.5 155.0, 197.7 157.0-157.9 162.0-162.9, 197.0 170.0-170.9, 198.5 174.0-174.9 180.0-180.9 182.0-182.8 183.0, 198.6 185.0 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

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ICD-9-CM diagnosis codes used in all settings (continued)

1_{Pain must be specifically documented as “chronic” to use code 338.29. Similarly the diagnostic term “chronic pain syndrome” must be specifically}

documented to use code 338.4. 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 E0783

Infusion pump system, implantable, programmable (includes all components)

Programmable Pump Only

(Replacement) E0786

Implantable programmable infusion pump,

replacement, does not include implantable catheter.

Intraspinal Implantable

Catheter Only E0785

Implantable intraspinal catheter used with implantable infusion pump, replacement

Infumorph™_{(preservative-}

free morphine sulfate sterile solution)4

J2274 Injection, morphine sulfate, perservative-free for epidural or intrathecal use, 10 mg

Anesthetic Drug

Administered Through IV J7799

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, 2015. Previous temporary code Q9974 (effective July 1, 2014 through December 31, 2014) and previous}

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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 Average5

Procedure Code Code Description Physician_Office Facility

Trial6,7

62311

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

62319

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

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

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CPT

®

_{Procedure Codes (continued)}

Implantation, or Replacement of Pump

62362

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

62355 Removal of previously implanted intrathecal or epidural

catheter N/A $280

62365

Removal of subcutaneous

reservoir or pump previously implanted for intrathecal or epidural infusion N/A $309 Fluoroscopy for Catheter Placement and Injection7 77003 or 77003-26

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)

$86 $86

Drug8 _J2274 Injection, morphine sulfate, preservative-free for

epidural or intrathecal use, 10 mg ASP+6% —

Refill/Analysis/

Reprogramming9

62367

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill

$41 $26

62368

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming

$57 $36

62369

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill10

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CPT

®

_{Procedure Codes (continued)}

Refill/Analysis/

Reprogramming9

62370

Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill (requiring skill of a physician or other qualified health care professional)10

$129 $48

95990

Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed

$91 –

95991

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 61070

Puncture of shunt tubing or reservoir for aspiration or

injection procedure N/A $60

Evaluation and Management

99211-

99215 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}

$35.7547 through March 31, 2015 in accordance with the CMS-1612-FC, Center for Medicare & Medicaid Services PFS Relative Value File (January release) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/physicianFeeSched/Downloads/CY2015-PFS-FR-RVU.zip. Published December 30, 2014. 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 62311 is used for needle injection or when a catheter is placed to administer one or more injections on a single calendar}

day. CPT code 62319 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 77003 is prohibited because 62311 and 62319 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. 67579. https://Federalregister.gov/a/2014-26183. Published November 13, 2014.