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Thread: Ketamine infusion for RSD

  1. #1

    Default Ketamine infusion for RSD

    AAPC: Back to School
    I am researching Ketamine infusion for pain management of patients with RSD. Usually this is infused over several days; may take a few hours to infuse. Would it be appropriate to bill IV infusion? Possibly 96365 + add-ons as appropriate. Plus the appropriate J code for the Ketamine. My question, is this a billable and payable service to insurances with this diagnosis and use of Ketamine? I am in the early stages of research, so any guidance as to where to start would be helpful. I have researched "Ketamine" in my local Medicare carrier's medical policies, but none appeared. I know all services have to meet medical necessity. How do I determine if Ketamine is appropriate to be used and administered in this way? My gut says that if there is no support for its use in that manner, then the service may not fly as medically necessary. And while Medicare may initially pay for IV infusion, after a review, it may not meet the medical necessity requirement and then be revoked. I want to avoid RACs and any other letter combinations as much as possible!

  2. #2
    Join Date
    Apr 2007
    Denver Colorado


    Often the Ketamine infusion is performed in a facility setting rather than a physician office which means that the IV infusion codes are not billable by the physician. See the CPT section guidelines for the 9636X codes. If performed in a facility setting, the documentation may support an E/M code but the physician would need to have a face-to-face service & documentation, etc.

  3. #3

    Default to follow up on Ketamine infusion

    What if it is done in an office setting? How does that work for billing purposes if an infusion nurse performs the service and monitors the patient? We do not currently perform many services in our own office, other than OMT and some acupuncture that the physician performs himself. We do not have any other types of providers (nursing, etc.) that might create incident-to or other billing scenarios. We understand that this opens a whole new world for staffing, billing, coding, etc. that we haven't directly dealt with in the past. Does the infusion of Ketamine change what type of place of service we would need to be?

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