Coding Intrathecal Injections for
Treating Chronic Intractable Pain
Deborah C. Hall, CPC
Basically, an intrathecal injection is the administration of a substance through the theca (dura matter) of the spinal cord
into the subarachnoid space. Intrathecal injections usually are performed for the treatment of chronic intractable pain, severe spasticity of the spinal cord (usually from spinal cord injuries) and/or chemotherapy of central nervous system lymphomas.
This article will focus on intrathecal injections for the infusion of drugs in treating chronic pain.
Test dosing or temporary catheter placement for trial screening is usually performed. This may be conducted on an outpatient basis but, usually, is administered in the hospital. A catheter is placed in the intrathecal space and attached to an external pump that patients wear on their belts.
Once patients pass this screening process (achieving adequate pain control), they become pump implantation candidates.
A qualified physician (anesthesiologist, neurosurgeon or surgeon) creates an incision over the appropriate intravertebral interspace and dissects through the subcutaneous tissues down to the meninges, which are opened. The appropriate catheter is threaded into the intrathecal space and secured by sutures in multiple sites.
Then, the free end of the catheter is brought under the subcutaneous tissues from the incision site and around the flank. The surgeon makes a second incision into the abdominal cavity (or another selected site) and creates a pocket into which the pump is placed. The free end of the catheter is brought into this site and attached to the pump. Both incision sites are closed, and the pump is activated.
Usually, patients are hospitalized for three days or more. During this time, they are monitored for cerebrospinal fluid leak, surgical wound protection and proper pump operation.
Indications and Coverage Issues
Certain criteria must be met before Medicare and many non-Medicare payers, including Worker's Compensation, will pay for implantable infusion pumps for chronic pain treatment. First, patients must have a life expectancy of greater than three months. Their history must indicate that they have not responded to less invasive pain control methods (including attempts to eliminate physical and behavioral abnormalities that may cause an exaggerated pain reaction).
In addition, systemic (oral, rectal or intravenous) analgesics cause intolerable side effects and produce ineffective pain control. Maximum radiation therapy is being given to the pain site (when applicable). The patient has a positive response to the drug used during the screening phase before pump implantation. Patients also must experience good to excellent pain relief from test dosing with minimal side effects (including activities of daily living).
In many cases, payers (such as Worker's Compensation) require providers to get their written preauthorization.
CPT Code Assignment
The nervous system subsection of the CPT manual surgery section includes both percutaneous (for the "test") or incisional catheter insertion codes. For percutaneous placement, assign CPT codes 62274, 62276 and 62277.
Before assigning the codes, determine the type of substance administration (e.g., single, differential or continuous injection). As stated, these services usually are performed during the trial screening period. Because these codes have a global surgical period of zero days, you also may code follow-up care (e.g., subsequent hospital visits and medication management).
To indicate the infusion pump implantation, two codes must be assigned--one for the catheter placement and one for the pump implantation. Correct code assignment for the catheter placement depends on whether a laminectomy was performed. Code 62350 indicates the implantation, revision or repositioning of the intrathecal or epidural catheter without a laminectomy, whereas 62351 indicates the same service with a laminectomy (more commonly performed by a neuro- or orthopedic surgeon).
Choose a code from the 62360-62368 range to describe services related to the implantation and programming of the reservoir or pumps. Code 62360 indicates the implantation or replacement of the intrathecal or epidural drug infusion reservoir, and 62361 describes non-programmable pump placement. More commonly, though, the implantation or replacement of a programmable pump is performed (62362). It includes the preparation and programming of the pump and the creation of the pocket into which the pump is placed.
Periodically, electronic analysis of the pump is performed to evaluate the status of the reservoir, alarm and drug. This enables the physician to reprogram (e.g., decrease or increase the amount or frequency of pump delivery rate). Code 62367 indicates analysis without reprogramming while 62368 is used for encounters where the device is reprogrammed.
The physician or a registered nurse can refill the pump in five to 30 minutes in an outpatient setting. Usually, the anesthesiologist manages the medication. It may be confusing, however, to locate the appropriate code because it is found in the chemotherapy administration subsection of the medicine section of the CPT manual.
Report 96530 for the pump refilling and maintenance. In addition, assign an evaluation and management (E&M) code for the pump refill if the necessary key components for the selected level of service have been met or exceeded. If the only service provided during the encounter is the pump refill (i.e., no history, exam or medical decision-making), do not assign an E&M code.
In the past, infusion pumps were used mainly to treat intractable cancer pain. Now, this pain-control treatment is used for pain caused by other diseases or conditions. Prior to treatment, contact your Medicare contractor. The payer's medical staff will verify the appropriateness and medical necessity of the treatment (location and type) before you submit the claim.
When assigning ICD-9-CM codes for this service, make sure the diagnosis chosen indicates the location of the patient's pain (e.g., back) as the primary diagnosis and the reason for the patient's condition (e.g., arachnoiditis) as the secondary diagnosis. Failure to list the diagnosis code for pain may result in a claim denial just as quickly as failure to list the reason for the pain. *
Deborah C. Hall is a senior health care consultant with Medical Learning Inc., St. Paul, MN.