Implant Billing Worksheet
Patient Name:______________________________________________________
Physician Name:_______________________________________________________
Intrathecal Drug Delivery System
Date:________________________________ Time:_______________________
□ Trial □ Implant □ Replacement
Payer:_________________________________
Physician Signature:___________________________________________________
(Check applicable boxes within each category)
Inpatient Facility
Outpatient Facility
Trial
Trial
ICD-9 Procedure
ττ #03.90 Catheter insertion
ττ #03.92 Injection of other agent into spinal canal
CPT Code
ττ 62311 Injection, single (not via indwelling catheter)
ττ 62319 Injection, including catheter placement, continuous infusion or Intermittent bolus
Implant or Replacement of Intraspinal Catheter
Implant, Revision, or Replacement Intraspinal Catheter
ICD-9 Procedure
ττ #03.90 Catheter insertion
ττ #03.92 Injection of other agent into spinal canal
CPT Code
ττ 62350 Catheter implantation without laminectomy
ττ 62351 Catheter implantation with laminectomy
ττ 77003 Fluoroscopy, guidance of catheter tip
Implant or Replacement of Infusion Pump
Implantation or Replacement of Pump
ICD-9 Procedure
ττ #86.06 Insertion of totally implantable infusion pump
CPT Code
ττ 62362 Programmable pump implantation
Removal of Catheter
Removal of Catheter or Pump
ICD-9 Procedure
ττ #03.99 Catheter removal
CPT Code
ττ 62355 Removal of Intrathecal Catheter
ττ 62365 Removal of Pump
Removal of Pump
C-Code (Medicare-outpatient only)
ICD-9 Procedure
ττ #86.05 Pump removal
ττ C1772 Programmable Infusion pump
ττ C1755 Intraspinal Catheter
E-Code (As required by payer)
Medicare’s consolidated device edits require that when specific CPT procedure codes
for device implantation are billed, the associated HCPCS (C-code) must also be billed.
ττ E0783 Entire Infusion pump system
ττ E0786 Programmable pump only replacement
ττ E0785 Intraspinal Catheter only-replacement
myPTM
ττ A9900 myPTM-misc DME supply-used during system replacement only-otherwise
included in E0783
Current Procedural Terminology (CPT) is copyright 2010 American Medical Association, all rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.
Medtronic has compiled this coding information for your convenience. It is always the provider’s responsibility to determine coverage and submit appropriate codes, modifiers, and charges for the services that were rendered. Please contact your local
Medicare Administrative Contractor/payer for interpretation of appropriate coverage and coding policies.
Accessories and Supplies
Product #
NDC
HCPCS II Codes and Description
Concentration
Total Volume
in Kit
Total Drug
Qty
Billing Units
Total Billable
per Kit
Units Used
(1 unit = 10 mg)
8561
58281-0560-01
J0475 Injection, baclofen, 10 mg
500 mcg/mL
20 mL
10 mg
1
8565
58281-0560-02
J0475 Injection, baclofen, 10 mg
500 mcg/mL
40 mL
20 mg
2
8564
58281-0563-01
J0475 Injection, baclofen, 10 mg
2000 mcg/mL
20 mL
40 mg
4
8566
58281-0563-02
J0475 Injection, baclofen, 10 mg
2000 mcg/mL
40 mL
80 mg
8
8562
58281-0561-02
J0475 Injection, baclofen, 10 mg
2000 mcg/mL
10 mL
20 mg
2
8563S
58281-0562-01
J0476 Injection, baclofen, 50 mcg for intrathecal trial
50 mcg/mL
1 mL
.05 mg
1
Coverage of discarded drugs applies only to single-use vials. Multi-use vials are not subject to payment for discarded amounts of drug. An itemized bill should be submitted with the
claim to verify how drug was supplied. The claim should include amount of drug administered and amount wasted. check with payer if JW modifier required. Reference CMS Manual
100-4, Chapter 17, subsections 40 or other payer requirements.
Trial
Catheter
ττ 8516 Percutaneous intraspinal trial catheter kit
ττ 8590-8 Catheter accessory kit
ττ 220289 ambIT cassette
ττ 8590-9 Catheter accessory repair kit
ττ 220246 ambIT lock box
ττ 8709SC InDura 1P intrathecal catheter (sutureless pump connector)
ττ 220275 ambIT pole clamp
ττ 8731SC Intrathecal catheter (sutureless pump connector)
ττ 220287 External Epidural ambIT pump
ττ 8711 InDura free-flow intrathecal catheter
ττ 220249 ambIT pump carrying pouch
ττ 81192 AlgoLine catheter with closed tip
ττ 8590-1 SynchroMed mesh pouch
ττ 8575 40 degree pump connector
ττ 8577 90 degree pump connector
ττ 8578 sutureless pump connector
ττ 863720 SynchroMed II infusion pump
ττ 863740 SynchroMed II infusion pump
ττ 81102 AlgoLine catheter kit with closed-tip long strain-relief
ττ 8583 Catheter passer (38 cm hollow stainless steel tunneling device with polypropylene obturator for use with
the Model 8731SC intrathecal catheter)
ττ 8586 Catheter passer (60 cm hollow stainless steel tunneling device with polypropylene obturator for use with
the Model 8731SC intrathecal catheter)
ττ 8591-38 Catheter passer (38 cm hollow stainless steel tunneling device with removable handle and
polypropylene obturator for use with the Models 8709 and 8709SC intrathecal catheters)
ττ 8591-60 Catheter passer (60 cm hollow stainless steel tunneling device with removable handle and
polypropylene obturator for use with the Models 8709 and 8709SC intrathecal catheters)
ττ 8596SC Pump segment revision kit (sutureless pump connector)
Catheter Access Port Kits
ττ 8598A Spinal segment revision kit
ττ 8540 SynchroMed catheter access port (CAP) kit
Analgesics
Notes/Other:
NDC
HCPCS II Codes and Description
Concentration
Total Billable Units Used
J2275 Injection, morphine sulfate
(preservative-free sterile solution), per 10 mg
J2278 Ziconotide, injection, 1 mcg
Current Procedural Terminology (CPT) is copyright 2010 American Medical Association, all rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.
Medtronic has compiled this coding information for your convenience. It is always the provider’s responsibility to determine coverage and submit appropriate codes, modifiers, and charges for the services that were rendered. Please contact your local
Medicare Administrative Contractor/payer for interpretation of appropriate coverage and coding policies.
UC201004233b EN NP9342b © 2011 Medtronic, Inc. Printed in USA.
SynchroMed Pump