Eli's Rehab Report

Published on Tue Oct 04, 2005 PDF

Question: I reported 95990 for a baclofen pump refill administered by a nurse, and received a denial from Medicare. Medicare referred me to the policy "Implantable Neuraxial Drug Admin Systems." This states that 95990 will not be reimbursed after April 1, 2004. So what exactly does this mean? Can I still report the nurse's services under 95991?


Ohio Subscriber

Answer: Depending on the carrier, you may not be compliant if you coded the nurse's services using 95991 (Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal [intrathecal, epidural] or brain [intraventricular]; administered by physician). The code description specifically states, "administered by physician." Palmetto GBA, the Medicare carrier for Ohio, decided in its local coverage determination that it will process payment only when a physician (MD or DO) performs the refill. In other words, your physician provider needs to perform the refill services for all Medicare patients.

Note: Other Medicare carriers are not so restrictive. Some will allow nonphysician practitioners (such as physician assistants or nurse practitioners) to perform 95990 and receive reimbursement. Check with your payer for its requirements.

FYI: CMS changed the PC/TC (professional component/technical component) indicator in the national relative value file effective July 1 for 95990 to a "5" or "Incident-To Codes." This indicator identifies codes that describe services covered incident-to a physician's service when auxiliary personnel--employed by the physician and working under his direct personal supervision--provide them. Carriers may not pay these services when a hospital outpatient department provides them to hospital inpatients or patients. You cannot use modifiers 26 (Professional component) and TC (Technical component) with these codes.