|Home | About | Journals | Submit | Contact Us | Français|
Infusion pumps are used in many different regimens to administer chemotherapy. This issue focuses on the coverage and coding of infusion pumps.
Question: Does Medicare have national coverage guidelines for infusion pumps?
Answer: Yes. The Centers for Medicare & Medicaid Services (CMS) has established national guidelines for the coverage of implanted and external (portable) infusion pumps. CMS' national coverage guidelines can be found in the National Coverage Determinations Manual, Chapter 1, Section 280.14 or at www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp.
Medicare's national guidelines provide specific coverage policies for the use of implanted and portable infusion pumps. For example, implanted infusion pumps are covered when used for the intra-arterial infusion of 5-FudR for the treatment of liver cancer. The primary diagnosis must be hepatocellular carcinoma or Duke's Class D colorectal cancer where metastases are limited to the liver. The guidelines specify that use of the implanted pump is covered only if the disease is unresectable or the patient refused surgical excision of the tumor.
Regional carriers administering Medicare benefits for durable medical equipment, called durable medical equipment carriers (DMERCs), may establish regional coverage policies for indications and uses not specified in the national guidelines. More information on DMERCs can be found on CMS' Web site at http://www.cms.hhs.gov/suppliers/dmepos/.
Question: Is there a specific CPT code we should use to report drug administration(s) provided through infusion pumps?
Answer: Yes. The American Medical Association's (AMA's) 2005 Current Procedural Terminology (CPT) code book identifies code 96414 as the initiation of a prolonged chemotherapy infusion lasting more than 8 hours that requires the use of a portable or implantable pump. This CPT code should be recognized by most private insurers.
As of January 2005, Medicare implemented a new G-code, G0361, to be used for the initiation of a prolonged chemotherapy infusion lasting more than 8 hours that requires the use of a portable or implanted pump. If this service is furnished to a Medicare beneficiary, code G0361 should be reported.
Question: Are disposable pumps covered by Medicare?
Answer: No. Medicare covers pumps that are considered durable medical equipment (DME). According to Medicare, durable medical equipment must withstand repeated use, be primarily and customarily used to serve a medical purpose; not useful to a person in the absence of an illness or injury; and be appropriate for use in the home. A disposable pump does not meet the durable medical equipment criteria; therefore, disposable pumps are not covered by the Medicare program. Drugs administered by pump are generally covered only if the pump itself is covered, so the drugs administered through disposable pumps would also not be covered.
Question: We have a patient who comes in for a chemotherapy treatment that is administered via an infusion pump. Even though we are utilizing the pump, the patient remains in the office during the 6-hour treatment. Can we use the prolonged infusion code?
Answer: Infusions lasting less than 8 hours should be reported as nonpump infusions (either 96410 and 96412 or G0359, G0360, G0362, respectively for Medicare beneficiaries). Only those infusions longer than 8 hours and requiring the patient to leave with the pump should be billed with the prolonged infusion code.
Question: A patient is receiving a chemotherapy regimen that requires the infusion of one drug for 22 hours on the first day and 22 hours on the following day. We billed the prolonged infusion code for the first day. Can we bill for the second day when the pump is refilled?
Answer: Yes. The patient had a pump initiated on the first day and then came back on the following day to have the pump refilled. If the portable pump is refilled on the following day (or subsequent day[s]), you can report the service of refilling. The service of refilling and maintenance of a portable pump is identified as CPT code 96520.
Question: Can we bill when the patient comes in to have the pump disconnected?
Answer: According to Medicare policy, if the patient comes in to the office for the sole purpose of having a pump unhooked by a nurse, a level-one office visit (99211) may be billed.
Question: We are providing a chemotherapy regimen in which the patient receives a continuous infusion of a drug for 3 days. The patient comes in to have the pump connected and comes back in on the third day to have the pump disconnected. This treatment regimen is repeated weekly for 4 weeks. Do we bill the prolonged infusion code for the first week and the refill code for each of the following weeks?
Answer: A prolonged infusion code (96414 or G0361) would be reported when the pump is connected on the first day (day one) of each treatment cycle. The infusion pump runs continuously over 3 days without having to be refilled; therefore, the refill code would not be reported. When the patient returns to have the pump disconnected, if that is the only service provided, a 99211 may be billed. Each treatment cycle is billed individually.
This column is intended to provide oncology practitioners and their staff with important information about reimbursement, coding, coverage, and regulatory policies. Topic suggestions or questions for future issues should be sent to gro.ocsa@ecitcarp.