Billing and Coding: Implantable Infusion Pump

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Implantable
Infusion Pump L33461.

Compounded medications are created by a pharmacist in accordance with the
Federal Food, Drug and Cosmetic Act and may be covered under Medicare when
their use meets all other criteria for services incident to a physician's
service.

Compounded medications do not have a National Drug Code (NDC) number, an
average sales price (ASP) or an average wholesale price (AWP). Accordingly,
the specific HCPCS J codes for the drugs in the compounded formulation may not
be submitted. Instead, providers must use HCPCS code J7999-KD (compounded
drug, not otherwise classified) for reimbursement of the compound medications.

The use of compounded drugs has been especially prevalent in the filling of
implantable infusion pumps. Whether a single agent or a combination of agents
is used, the compounded medication must be submitted with HCPCS code J7999-KD,
even though the compound is similar to or includes a drug with a specific
HCPCS code (e.g., HCPCS code J2274 for preservative free morphine). Non-
compounded drugs administered via durable medical equipment (DME), are
reimbursed based on Centers for Medicare and Medicaid Services (CMS) ASP
methodology. Providers who document and use the true off-the-shelf product
without compounding may continue to use the drug specific HCPCS code.

When billing compounded medications, submit HCPCS code J7999-KD on a single
claim line and enter the quantity billed as '1'. Enter the name and total dose
(in mg. or mcg.) of each drug in Box 19 of the CMS 1500 or the appropriate
comment loop of electronic claims. Example: Unit of 1 J7999-KD claim line
detail: Entered in Box 19/5010 comment field 'Morphine Sulfate XX mg +
Fentanyl YY mcg + Clonidine ZZ mcg'. If Box 19 cannot accommodate all of the
information, attach the information to the paper claim.

Separate payment may be made for refilling and/or pump adjustments as
clinically appropriate. These services should be submitted using the correct
drug refill or maintenance code that accurately describes the service
rendered. Evaluation and management services are not separately payable unless
the practitioner provides a significant, separately identifiable service.

Compounded drugs are priced by the contractor. Palmetto GBA will reimburse
compounded drugs for use in implanted infusion pumps by multiplying the price
per mcg. or mg. by the total number of mcg. or mg. of each drug used to refill
the pump. A pharmacy compounding fee will be allowed, in addition to the
calculated amount for the drug(s), in order to arrive at the total Medicare
allowable for the refill.

Prialt is a drug only available from the pharmaceutical manufacturer. If
given as a single drug in the pump, use code J2278-KD. If mixed with other
drugs in the pump, consider the mixture a compounded drug and use the HCPCS
code J7999-KD. If a portion of a single dose vial of a medication is not used,
submit the HCPCS code for the drug on a separate claim line and append the JW
modifier.

CPT/HCPCS codes used for Opioid Drugs for the Treatment of Chronic
Intractable Pain are J7999KD, E0782, E0783, E0785, E0786, 62327, 62350, 62351,
62355, 62361, 62362, 62365, 62367, 62368, 62369, 62370, 95990 and 95991.