Targeted Drug Delivery for Chronic Pain and Cancer Pain ...

[Pages:27]TARGETED DRUG DELIVERY TCAORMGMETOENDLYDBRIULGLEDDECLIOVEDREYS FOR CHRONIC PAIN COMMONLY BILLED CODES

EFFECTIVE JANUARY 1, 2020

EFFECTIVE JANUARY 1, 2021

TARGETED DRUG DELIVERY COMMONLY BILLED CODES

TABLE OF CONTENTS

ICD-10-CM Diagnosis Codes............................................................... 3 ICD-10-PCS Procedure Codes............................................................ 7 HCPCS II Device Codes (Non-Medicare).............................................. 8 Device C-Codes (Medicare)................................................................. 8 Device Edits (Medicare)....................................................................... 9 HCPCS II Drug Codes.......................................................................... 9 Physician Coding and Payment............................................................ 10 Hospital Outpatient Coding and Payment........................................... 13 Hospital Inpatient Coding and Payment Non-Cancer Pain................... 17 Hospital Inpatient Coding and Payment Cancer Pain........................... 20 ASC Coding and Payment.................................................................... 24

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TARGETED DRUG DELIVERY COMMONLY BILLED CODES

Medtronic provides this information for your convenience only. It does not constitute legal advice or a recommendation regarding clinical practice. Information provided is gathered from third-party sources and is subject to change without notice due to frequently changing laws, rules and regulations. The provider has the responsibility to determine medical necessity and to submit appropriate codes and charges for care provided. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other payers as to the correct form of billing or the amount that will be paid to providers of service. Please contact your Medicare contractor, other payers, reimbursement specialists and/or legal counsel for interpretation of coding, coverage and payment policies. This document provides assistance for FDA approved or cleared indications. Where reimbursement is sought for use of a product that may be inconsistent with, or not expressly specified in, the FDA cleared or approved labeling (eg, instructions for use, operator's manual or package insert), consult with your billing advisors or payers on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service.

The following information is calculated per the footnotes included and does not take into effect Medicare payment reductions resulting from sequestration associated with the Budget Control Act of 2011. Sequestration reductions went into effect on April 1, 2013.

For questions please contact us at neuro.us.reimbursement@

ICD-10-CM1 Diagnosis Codes

Diagnosis codes are used by both physicians and hospitals to document the indication for the procedure.

Targeted Drug Delivery (TDD) is directed at managing chronic, intractable pain. Pain can be coded and sequenced several ways depending on the documentation and the nature of the encounter. Pain codes from the G89 series are used as the principal diagnosis when the encounter is for pain control or pain management, rather than for management of the underlying condition. Additional codes may then be assigned to identify the underlying cause and give more detail about the nature and location of the pain. When a specific pain disorder is not documented or the encounter is to manage the cause of the pain, the underlying condition is coded and sequenced as the principal diagnosis.2

Chronic Pain Disorders

G89.0

Central pain syndrome

G89.29

Other chronic pain

G89.3

Neoplasm related pain (acute)(chronic)

G89.4

Chronic pain syndrome

Note: "Central pain syndrome" and "chronic pain syndrome" are diagnoses and must be specifically documented to assign code G89.0 or G89.4. Similarly, pain must be documented as "chronic" to assign code G89.29, and must be

documented as being related to the neoplasm to assign G89.3.

Reflex Sympathetic Dystrophy (RSD) (Complex Regional Pain Syndrome I) (CRPS I)

And

Causalgia (Complex Regional Pain Syndrome II) (CRPS II)

G90.521 G90.522 G90.523 G90.529 G57.70 G57.71

Complex regional pain syndrome I of right lower limb Complex regional pain syndrome I of left lower limb Complex regional pain syndrome I of lower limb, bilateral Complex regional pain syndrome I of unspecified lower limb Causalgia of unspecified lower limb Causalgia of right lower limb

G57.72

Causalgia of left lower limb

G57.73

Causalgia of bilateral lower limbs

Note: ICD-10-CM does not have a default code for "Complex Regional Pain Syndrome"; type I or II must be specified. Pain codes from the G89 series should not be assigned separately with the codes for reflex sympathetic dystrophy or causalgia because pain is a known component of these disorders.

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TARGETED DRUG DELIVERY COMMONLY BILLED CODES

ICD-10-CM1 Diagnosis Codes continued

Underlying Causes of

Postherpetic Neuropathy/Neuralgia

Chronic Pain (Non-Cancer)

B02.22

Postherpetic trigeminal neuralgia

B02.23

Postherpetic polyneuropathy

B02.29

Other postherpetic nervous system involvement (radiculopathy)

Arachnoiditis

G03.1

Chronic meningitis

G03.9

Meningitis, unspecified

Peripheral Neuropathy of Lower Extremities

G57.90

Unspecified mononeuropathy of unspecified lower limb

G57.91

Unspecified mononeuropathy of right lower limb

G57.92

Unspecified mononeuropathy of left lower limb

G57.93

Unspecified mononeuropathy of bilateral lower limbs

Radiculopathy

M51.16

Intervertebral disc disorders with radiculopathy, lumbar region

M51.17

Intervertebral disc disorders with radiculopathy, lumbosacral region

M54.16

Radiculopathy, lumbar region

M54.17

Radiculopathy, lumbosacral region

Osteoporosis-Related Fracture, Vertebra3

M80.08xA M80.88xA

Age-related osteoporosis with current pathological fracture, vertebra(e) Other osteoporosis with current pathological fracture, vertebra(e)

Postlaminectomy Syndrome

M96.1

Postlaminectomy syndrome, not elsewhere classified

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ICD-10-CM1 Diagnosis Codes continued

Underlying Causes of Chronic Pain (Cancer)4

C15.3-C15.9 C16.0-C16.9

Malignant neoplasm of esophagus Malignant neoplasm of stomach

C18.0-C18.9, C19, C20, Malignant neoplasm of colon, rectosigmoid junction, rectum, anus, C21.0-C21.8, C78.5 and anal canal

C22.0-C22.9, C78.7 Malignant neoplasm of liver and intrahepatic bile ducts

C25.0-C25.9

Malignant neoplasm of pancreas

C33, C34.00-C34.92 Malignant neoplasm of trachea, bronchus and lung C78.00-C78.02

C40.00-C40.92 Malignant neoplasm of bones C41.0-C41.9, C79.51

C50.011-C50.929 Malignant neoplasm of breast

C53.0-C53.9

Malignant neoplasm of cervix

C54.0-C54.9, C55 Malignant neoplasm of uterus

C56.1-C56.9 C79.60-C79.62

C61

Malignant neoplasm of ovary Malignant neoplasm of prostate

C62.00-C62.92 Malignant neoplasm of testis

C64.1-C64.9, C65.1-C65.9, C79.00-C79.02

Malignant neoplasm of kidney

C67.0-C67.9, C79.11 Malignant neoplasm of bladder

C71.0-C71.9 C72.0-C72.9

C79.31 C79.40-C79.49

Malignant neoplasm of brain, spinal cord, and other central nervous system structures

M84.58xA

Pathological fracture in neoplastic disease, other specified site (vertebrae)3

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TARGETED DRUG DELIVERY COMMONLY BILLED CODES

ICD-10-CM1 Other Diagnosis Codes

Device Complications3,5,6

T85.610A

Breakdown (mechanical) of cranial or spinal infusion catheter

T85.615A T85.620A

Breakdown (mechanical) of other nervous system device, implant or graft Displacement of cranial or spinal infusion catheter

T85.625A

Displacement of other nervous system device, implant or graft

T85.630A T85.635A T85.690A

Leakage of cranial or spinal infusion catheter Leakage of other nervous system device, implant or graft Other mechanical complication of cranial or spinal infusion catheter

T85.695A T85.735A T85.738A T85.830A T85.840A

Other mechanical complication of other nervous system device, implant, or graft Infection and inflammatory reaction due to cranial or spinal infusion catheter Infection and inflammatory reaction due to other nervous system device, implant, or graft Hemorrhage due to nervous system prosthetic devices, implants, and grafts Pain due to nervous system prosthetic devices, implants and grafts

T85.890A

Other specified complication of nervous system prosthetic devices, implants and grafts7

Attention to Device8

Z45.49

Encounter for adjustment and management of other implanted nervous system device

1. Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). . Updated October 1, 2020.

2. ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, I.C.6.b. 3. Fracture and device complication codes ending in "A" are technically defined as "initial encounter" but continue to be assigned for each encounter in which the patient is receiving

active treatment for the facture or complication (ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, I.C.19.A). 4. The most common anatomic sites for primary and secondary cancer are displayed. Codes for other sites are also availabl e within code range C00-C96. 5. When a device complication is the reason for the encounter, the device complication code is sequenced as the principal diagnosis followed by a code for the underlying condition. If

the purpose of the encounter is directed toward the underlying condition or the device complication arises after admission, t he underlying condition is sequenced as the primary diagnosis followed by the device complication code. 6. According to ICD-10-CM manual notes, codes defined for "cranial or spinal infusion catheter" include intrathecal and subarachnoid infusion catheters, and codes defined for "other nervous system device, implant or graft" include intrathecal infusion pumps. 7. According to ICD-10-CM manual notes, "other specified complication" includes erosion or breakdown of a subcutaneous device pocket. 8. ICD-10-CM code Z45.49 is used as the principal diagnosis when patients are seen for routine device maintenance, such as periodic pump device checks and programming, as well as routine device replacement. A secondary diagnosis code is then used for the underlying condition. (See also Coding Clinic, 3rd Q 2014, p.19-20.)

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TARGETED DRUG DELIVERY COMMONLY BILLED CODES

ICD-10-PCS1 Procedure Codes

Hospitals use ICD-10-PCS procedure codes for inpatient services.

Trial and Catheter Procedures Catheter Implantation2,3 00HU33Z

Insertion of infusion device into spinal canal, percutaneous approach

Intrathecal Injection

3E0R3NZ Introduction of analgesics, hypnotics, sedatives into spinal canal, percutaneous approach

Catheter Procedures Catheter Implantation2,3 00HU33Z

Insertion of infusion device into spinal canal, percutaneous approach

Intrathecal Injection

3E0R3NZ Introduction of analgesics, hypnotics, sedatives into spinal canal, percutaneous approach

Catheter Removal4

00PU03Z Removal of infusion device from spinal canal, open approach

00PU33Z Removal of infusion device from spinal canal, percutaneous approach

Catheter Replacement Two codes are required to identify a device replacement: one code for implantation of the new device and one code for removal of the old device.5

Catheter Revision6

00WU03Z 00WU33Z 0JWT03Z 0JWT33Z

Revision of infusion device in spinal canal, open approach Revision of infusion device in spinal canal, percutaneous approach Revision of infusion device in trunk subcutaneous tissue and fascia, open approach Revision of infusion device in trunk subcutaneous tissue and fascia, percutaneous approach

Pump Procedures Pump Implantation7,8

Pump Removal7,8

0JH80VZ 0JPT0VZ

Insertion of infusion pump into abdomen subcutaneous tissue and fascia, open approach

Removal of infusion pump from trunk subcutaneous tissue and fascia, open

0JPT3VZ Removal of infusion pump from trunk subcutaneous tissue and fascia, percutaneous approach

Pump Replacement

Two codes are required to identify a device replacement: one code for implantation of the new device and one code for removal of the old device.5

Pump Revision 9,10

0JWT0VZ 0JWT3VZ

Revision of infusion pump in trunk subcutaneous tissue and fascia, open approach Revision of infusion pump in trunk subcutaneous tissue and fascia, percutaneous approach

1. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD -10-PCS). . Updated October 1, 2020.

2. Approach value 3-Percutaneous is used because the catheter is placed by spinal needle via puncture or minor incision. 3. The Ascenda Intrathecal Catheter uses device value 3-Infusion Device per the ICD-10-PCS Device Key. 4. Approach value 0-Open is used when the catheter is removed by dissection to free the device. Approach value 3-Percutaneous is used when the catheter is removed by puncture.

Only the ICD-10-PCS codes for surgical removal of the catheter are displayed. Approach value X -External is also available for removal of catheter by simple pull. 5. CMS ICD-10-PCS Reference Manual 2016, p.67. See also Coding Clinic, 3rd Q 2014, p.19. 6. For catheter revision, the ICD-10-PCS codes using body part value U-Spinal Canal refer to surgical revision of the catheter within the spinal intrathecal space, eg, repositioning.

The ICD-10-PCS codes using body part value T-Subcutaneous Tissue and Fascia refer to revision of the subcutaneous portion of the catheter. 7. Placement of the pump is shown with approach value 0-Open because creating the pocket requires surgical dissection and exposure. Removal also usually requires surgical

dissection to free the device. 8. The SynchroMed II pump uses device value V-Infusion Device, Pump per the ICD-10-PCS Device Key. 9. For Pump Revision, the ICD-10-PCS codes shown can be assigned for opening the pocket for pump revision, as well as reshaping or relocating the pocket while reinserting the

same pump. 10. Approach value X-External is also available for external pump manipulation without opening the pocket, eg. to correct a flipped pump.

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TARGETED DRUG DELIVERY COMMONLY BILLED CODES

HCPCS II Device Codes1 (Non-Medicare)

These codes are used by the entity that purchased and supplied the medical device, DME, or supply to the patient. For implantable devices, that is generally the facility. HCPCS II device codes are only reported on physician office and facility outpatient bills.2 For specific Medicare hospital outpatient billing instructions for medical devices, see the Device C-Codes (Medicare) below.

Entire System (Catheter and Programmable Pump)

E0783 Infusion pump system, implantable, programmable (includes all components, eg, pump, catheter, connectors, etc.)

Programmable Pump only (replacement)

E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)

Intrathecal Catheter only (replacement)

E0785 Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement

Personal Therapy Manager (myPTMTM), SynchroMedTM II3,4

A9900 Miscellaneous DME supply, accessory, and/or service component of another HCPCS code (used for replacement only)

1. Healthcare Common Procedure Coding System (HCPCS) Level II codes are maintained by the Centers for Medicare and Medicaid Services. MedHCPCSGenInfo/index.html. Accessed December 15, 2020.

2. Although HCPCS II codes cannot be reported on an inpatient bill, some hospitals may choose to assign them with inpatient encounters strictly for internal tracking purposes. 3. The CMS HCPCS Workgroup maintains that the PTM is included as a component of E0783 when the system is initially implanted, regardless of whether the PTM is provided to the

patient at that time. See also Medicare Pricing Data Analysis and Coding (PDAC) database at searchProductClassificationResults.do?aciotnPath=search, under Personal Therapy Manager. If the PTM must later be replaced, code A9900 can be assigned. 4. Note that because ziconotide has a defined titration scheme, the Personal Therapy Manager is not prescribed or used for administration of an intrathecal infusion of Ziconotide.

Device C-Codes1 (Medicare)

Medicare provides C-codes, a type of HCPCS II code, for hospital use in billing Medicare for medical devices in the outpatient setting. Although other payers may also accept C-codes, regular HCPCS II device codes are generally used for billing nonMedicare payers.

ASCs, however, usually should not assign or report HCPCS II device codes for devices on claims sent to Medicare. Medicare generally does not make a separate payment for devices in the ASC. Instead, payment is "packaged" into the payment for the ASC procedure. ASCs are specifically instructed not to bill HCPCS II device codes to Medicare for devices that are packaged.2

Infusion Pump

C1772 Infusion pump, programmable (implantable)

Intrathecal Catheter

C1755 Catheter, intraspinal

1. Healthcare Common Procedure Coding System (HCPCS) Level II codes, including device C-codes, are maintained by the Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System. . Accessed December 15, 2020.

2. ASCs should report all charges incurred. However, only charges for non-packaged items should be billed as separate line items. For example, the ASC should report its charge for the generator but because the generator is a packaged item, the charge should not be reported on its own line. Instead, the ASC should bill a single line for the implantation procedure with a single total charge, including not only the charge associated with the operating room but also the charges for the generator device and all other packaged items. Because of a Medicare requirement to pay the lesser of the ASC rate or the line-item charge, breaking these packaged charges out onto their own lines can result in incorrect payment to the ASC. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 14--Ambulatory Surgical Centers, Section 40. . Accessed December 15, 2020. See also MLN Matters SE0742 Revised, p.9 -10. -Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0742.pdf. Accessed December 15, 2020.

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