Article - Billing and Coding: Implantable Infusion Pump (A56695)

CMS National Coverage PolicyTitle XVIII Social Security Act, 1833(e)prohibits Medicare payment for any claim lacking the necessary information to process that claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, 10-70.1.2 Drugs and BiologicalsCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3,3.4.1.3 Diagnosis Code RequirementArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forImplantable 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 physicians 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.