Orthopedic Coding Alert

Avoid Fraud:

Stay Clear of Coding Pitfalls for Short-term Pain Pumps

While CPT has several codes for the placement of subcutaneous, long-term pain pumps, none exists for a short-term, external pump. The closest match is 90799 (unlisted therapeutic, prophylactic or diagnostic injection) because the pump is a means of injecting medication through a catheter. But short-term pain pumps inserted at the time of surgery are not a reimbursable service. Any potential CPT codes for pump insertion (in this case, 90799) are bundled in with the primary surgical procedure. Per the American Association of Orthopedic Surgeons (AAOS) Complete Global Service Data for Orthopedic Surgery, the insertion, placement, and removal of surgical drain(s), re-infusion device(s), irrigation tube(s), catheter(s), or suction device(s) are included in virtually every major orthopedic surgery.

In orthopedics, pain pumps are most often administered at the time of major surgery. The newer models of pain pumps are external devices that deliver anesthetic through a catheter directly to the surgical site, rather than intravenously as with older models. Proponents of pain pumps say the pump allows for the patient to be discharged earlier, in a more alert state with less pain. Temporary pumps are most often used for shoulder surgeries, during rotator cuff repairs (e.g., 23412, repair of ruptured musculotendinous cuff [e.g., rotator cuff]; chronic). The pump is inserted for about two days, and infuses anesthetic to the affected area for postsurgical pain management.

Because the majority of work involved in fitting a patient with a pain pump is the catheterization, it is not separately billable. Although the AAOS guidelines for bundling do not necessarily match those of commercial carriers, they are widely accepted as authoritative, and most commercial carriers will either follow the AAOS or Medicare guidelines, or have guidelines of their own that are even more restrictive.

For Medicare patients, the use of temporary pain pumps following surgery is deemed not medically necessary. Medicare considers the placement of a catheter at the operative site for pain management to be a part of the primary procedure and does not reimburse separately for it, says BillieJo McCrary, CPC, CCS-P, CMPC, practice manager of Wellington Orthopedic and Sports Medicine in Cincinnati. I am aware that some physicians have billed inappropriately using 62360, 62361 and 62362 (implantation or replacement of device for intrathecal or epidural drug infusion ...) to describe the placement of a subcutaneous catheter attached to a pump to administer a controlled release of pain medication to the operative site, but these are not codes for short-term pain-management pumps, she says.

Be Cautious With Supplier Recommendations

According to many orthopedic coders, suppliers of pain-infusion pumps have encouraged physicians and staff that inserting the pumps is billable but, in virtually all cases, it is not. Several have been instructed by their supplier to use 37202 (transcatheter therapy, infusion other than for thrombolysis, any type [e.g., spasmolytic, vasoconstrictive]). Some have even submitted this code and been paid. But this code cannot be used for implantation of pain-infusion pumps, because it is a cardiovascular code and can be used only in cardiovascular procedures. Carriers who reimbursed for this code likely did so because they did not know the surgeon wasnt performing a cardiovascular procedure. Continuing to submit and obtain reimbursement using this code can lead to an eventual audit and fraud allegations.

Julie McGregor, CMA, insurance coordinator for Sports Medicine and Joint Replacement Specialists in Ft. Myers, Fla., says that despite recommendations from pump suppliers, her surgeons have stopped using the pumps because they had no success getting reimbursed for the service. We were told by one supplier to bill using modifier -22 (unusual procedural services), but still had no luck in obtaining payment. Other suppliers suggested other codes, none of which seemed appropriate.

Supply May Be Reimbursable

While a temporary drug-delivery system such as an external pain pump is not covered by Medicare, some private carriers may reimburse for the pump supply. Using HCPCS code E0781 (ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient), some providers have had luck with reimbursement. But many carriers do not want to pay for a disposable drug-delivery system that is used for less than one week. In all cases, the coder should look to CPT or the carrier, rather than the pump supplier, for the right supply code to submit.

When billing for medication, coders will traditionally use the appropriate HCPCS J code. However, in the case of external pain pumps, the drug most commonly used is bupivicaine. This drug has been assigned a temporary national code and is not Medicare-reimbursable. But, for private payers, submit the HCPCS code S0020 (injection, bupivicaine hydrochloride, 30 ml). If the carrier involved does not accept J or S codes, bill using the national drug code (NDC) and dosage listed on the drug package.

Surgeons and coders may prefer to stay out of the pain-pump supply business, and simply apply the pumps at surgery rather than purchase and seek reimbursement for them. McCrarys surgeons obtain the pain pumps from the hospital, rather than supplying them directly to the patient. In other cases, the vendor will bill the patient or the insurance company directly, which many providers prefer. The same situation applies for the drug supply. If the medication is expensive, the orthopedic office may stay out of the billing process altogether and have the patients obtain the medication prior to surgery, either through prescription or via their insurance plans pharmaceutical supplier.

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