FIRST COAST SERVICE OPTIONS
LOCAL COVERAGE DETERMINATION
CODING GUIDELINES
Contractor’s
Determination Number
95990
LCD Database ID Number
L31254
Contractor Name
First
Coast Service Options, Inc.
Contractor
Number
09102 –
09202 – Puerto Rico
09302 –
LCD Title
Implantable Infusion Pump for the Treatment
of Chronic Intractable Pain
Coding
Guidelines
There are a variety of possible ICD-9-CM codes that have indications
associated with severe pain and are too numerous to list in this LCD. The most
appropriate ICD-9-CM code that supports the specific cause of the severe chronic intractable pain should
be reported.
All of the CPT codes related to the refilling and maintenance of the pump should be
billed and documented on the same claim form along with the procedure code for
the drugs that are administered through the pump. It is expected that all of these codes should
be billed on the same claim.
Note: Compounded drugs (combination of single drugs
or combination of drugs) used in an implantable infusion pump should be billed
with HCPCS code J3490 (Unclassified drugs) and modifier KD. Whether a combination of single drugs or a
combination of drugs are used, the compounded medication should be billed with
the HCPCS code J3490 along with the ‘KD’ modifier even though the compound was
similar to a unique HCPCS code (e.g., J2275 for preservative free
morphine). However, providers who
document and use the true “off-the-shelf” product from their office supply may
continue to use the unique HCPCS code with the
KD modifier. The only exception would
be HCPCS code J2278 (Injection, ziconotide, 1
microgram) which will automatically be reimbursed at 95% of
2003 AWP; this is based on the DME infusion payment requirement for drugs
furnished in an implantable infusion pump.
Do not report procedure codes 62367-62370 in conjunction with procedure
codes 95990 and 95991.
Definition of
Compounded Drug:
A compounded drug is a blend of drugs mixed (compounded) by a
pharmacist. This mixture is delivered to
the physician or qualified non-physician provider ready to infuse into an
implantable pump. At times, the
pharmacist may reconstitute only one substance and deliver it to the provider
in a ready to infuse form. An example of
reconstituting is adding saline solution to a medication that is supplied as a
powder and then turning it into a liquid.
Of note, a drug that is reconstituted outside the provider’s office and
is delivered to her/him for instillation into an implantable infusion pump is a
compounded drug. In summary, any drugs
that have been processed by a pharmacist outside of the provider’s office are
compounded drugs.
The written description of the drug dosage(s) in the medical record
documentation should be in micrograms (mcgs) or milligrams
(mgs).
The following should be indicated in item 19 of CMS 1500 Form or its
electronic equivalent when billing HCPCS code J3490.
·
The name of the drug(s) and dosage(s)
administered into the implantable infusion pump;
·
The volume of refill in milliters
(ml);
·
The pump reservoir size in milliters (ml);
·
Exact invoice price for that individual
patient claim for infusion drugs furnished via implanted DME, with dates of
service on or after January 1, 2004, shall be identified using the modifier KD;
and
·
The units billed should be one (1) in the
day/units field (item 24G) on CMS 1500 Form.
Comments
N/A
Revision History
|
Date |
Revision |
|
01/01/2012 |
1- Annual 2012
HCPCS Update. Added coding information
related to procedure codes 62367, 62368, 62369 (new), and 62370 (new). The effective date of this revision is
based on date of service. |
|
09/30/2010 |
Original |
Document formatted:
12/07/2011 (DE/et)