We just bill the pain pump refill on days they have it regardless of the above and beyond rule with never billing visit on those days. But technically the use of modifier 25 allows for a visit to be billed on the same day as a minor procedure if the carrier also allows and your advice is within the guidelines, but it is decision as a practice do you bill visits with minor procedures. We don't because our patients always seem have additional issues going on so we forgo billing the E/M
The AMA addresses when it is appropriate to bill an E/M with pump refills/reprogramming. Below is a portion from AMA CPT Assistant July 2006
Clinical Scenario 1
A patient with a history of a failed back syndrome presents to the pain clinic for a routine pump refill. She meets with the practice's registered nurse (RN), reports no new symptoms, and states that she has continued good pain control. The RN performs the refill of the spinal opioid delivery system. The physician sees the patient and reprograms the pump without changing the daily dosage. The patient is informed of her refill date and sent home.
CPT code 95990 is reported for the refill and maintenance of the implantable pump provided by the practice's RN. Code 62368 is reported for the reprogramming. No E/M service is reported for this scenario.
Clinical Scenario 2
A patient with a history of complex regional pain syndrome of the right lower extremity presents to the pain clinic for evaluation and refill of his pump. He is seen by the nurse for initial intake. The patient reports decreased libido, increased peripheral edema, and poor pain control. The nurse refills the pump. The physician sees the patient, reprograms the pump, orders laboratory tests to check for drug-induced hypogonadism, and recommends follow-up with the primary care provider for his peripheral edema and laboratory results. In addition, the physician adjusts the patient's oral medications to help with his pain. The physician spends 25 minutes counseling the patient.
CPT code 95990 is reported for the refill of the pump performed by the nurse. Code 62368 is reported for the reprogramming by the physician. The appropriate level E/M service code is reported with modifier 25 appended for the counseling provided by the physician.
Clinical Scenario 3
A patient with a history of osteoporosis and multiple compression fractures presents to the clinic for a refill of her implanted spinal opioid delivery system. She meets with the physician, complains of slight worsening of pain since her last visit, and requests that the dosage be increased. The physician performs the refill and reprograms the pump with a 10% increase in daily dosage. The physician does not prescribe any medication and does not manage any other medical issues.
CPT code 95991 is reported for the pump refill provided by the physician. Code 62368 is reported for the reprogramming. No E/M code is reported for this scenario.
Clinical Scenario 4
This scenario is similar to Clinical Scenario 3, but the physician also manages the patient's complaints of shoulder pain secondary to osteoarthritis. He prescribes a nonsteroidal anti-inflammatory drug and recommends a follow-up visit in one month for an intraarticular shoulder injection. The physician spends a total of 10 minutes patient contact time taking a history and examining the shoulder.
CPT code 95991 is reported for the refill of the pump provided by the physician. Code 62368 is reported for the reprogramming. The appropriate level E/M service code is reported with modifier 25 appended.
Clinical Scenario 5
This scenario is similar to Clinical Scenario 4, but the physician elects to inject the shoulder (in addition to the pump refill) due to lack of response to previous conservative treatment.
CPT code 95991 is reported for the refill of the pump provided by the physician. Code 62368 is reported for the reprogramming. Code 20610 is reported for the shoulder injection with modifier 59 appended to indicate that a distinct procedural service was performed by the same physician on the same date. The appropriate E/M service code is reported with modifier 25 appended.
Coding Tip
In Clinical Scenarios 1 through 5, the physician may report also the supply of drugs with CPT code 99070, Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided), or the appropriate HCPCS Level II J code(s).
Clinical Scenario 6
A patient presents for pump interrogation following an magnetic resonance imaging of the brain ordered by her primary care physician. The pump is interrogated by the practice's physician assistant (PA) and found to have no changes from the previous settings. No adjustments are made to the pump dosage. No physician is present in the office.
Code 62367 should be reported for the pump analysis. It is important to check with individual third-party payer policy and reporting guidelines for services reported by a PA because these may vary among payers.
Coding Update
Since the publication of the Coding Consultation in the November 2002 issue of CPT Assistant, codes 95990 and 95991 have been added to the CPT code set to describe the refill and maintenance of an implantable pump or reservoir for drug delivery to the spine or brain. Newly renumbered code 96522 (deleted 96530) is intended solely for chemotherapy pump refills. Based upon the previous published information, there appears to be a perception in the coding community that codes 95990 and 95991 cannot be separately reported with code 62368. A parenthetical reference following code 95991 has been added to instruct users to report codes 62367-62368 for analysis and/or reprogramming of an infusion pump. It would be appropriate, therefore, to report codes 95990 and 95991 in addition to code 62368 when performed at the same session. Thus, this information supersedes the previously published information from the Questions and Answers section of the November 2002 CPT Assistant (see Medicine: 96530, 62368 on page 10).