Implanted Intrathecal Pain Pump refills


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I work in the billing department of a pain management office. We are having issues with Blue Cross taking back money for J codes that are billed out when we refill the pumps.

Does anyone out in our AAPC world have time to let me ask some questions about this? I was told that Morphine, Baclofen and Prialt are all FDA approved for pain management. We also use dilaudid, fentanyl, Sufenta and a few others in the intrathecal pump. That makes these drugs "off label" and the money is now being taken back.

A few things I was told is that the J codes are only for FDA approved drugs. I can not find this anywhere...Does anyone have proof or denial of this?

Does anyone else have issues with this? Do you use only drugs that are FDA approved or do you have a patient sign an ABN and bill them for the medication refill? I am at a loss as to what to do and this can be quite a bit of money that is taken back.

I would appreciate any information on this. I have been brought into this with out any knowledge of intrathecal pain pump coding / billing experience.

Thank you for your time! :)


True Blue
Best answers
"Implantable infusion pumps are considered medically necessary when used to deliver drugs having FDA approval for this route of access and for the related indication for the treatment of...."

I searched BCBS implantable infusion pumps for pain and spasticity and it seems like every state that pulled up has the same statement regarding the drug has to be FDA approved for the route of access/condition. There are also BCBS plans that describe allowing compounded medications for pain pump refills with instructions on submitting a claim for that but I assume the compounded medications would have to fall under the FDA approval

I would pull the policy for the state you are in to verify then I would contact the representative in your state for pump manufacturer and ask them if they having any suggestions or you contact their general billing number.
For example Medtronics


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