American Society of Regional Anesthesia and Pain Medicine August 2018 - 30

Medical Necessity, Documentation, Coding, and Billing for
Intrathecal Therapy
BACKGROUND
Intrathecal (IT) drug delivery systems are effective for patients with
refractory chronic pain, and their use in the United States has been
continuously increasing.1-3 IT therapy provides a valuable option
for patients in whom oral or transdermal opioids are ineffective at
reasonable doses or cause unacceptable side effects.4,5 Compared
with oral or parenteral routes for pain control, IT delivery uses
significantly lower doses of opioids to directly deposit medications
near the spinal cord receptors, bypassing the blood-brain barrier,
which has led to markedly reduced adverse events.2,6,7
Most IT pumps are placed for failed back surgery syndrome, but
they are indicated for other types of cancer or noncancer pain as
well.2,3,8 Currently, morphine and ziconotide are the only two agents
approved by the Food and Drug Administration for IT analgesia;
however, use of other agents is common among pain practitioners.
Quality-of-life measures are improved and overall health care use
costs are decreased in selected
patients with IT therapy when
compared with conventional
medical management.9
Although it has historically
been positioned as a salvage
therapy, IT therapy is now
being considered earlier in the
treatment spectrum.10

2013 Medicare reimbursement
rates, the median cost was
$10.46/d. (That cost was only
for the hardware and did not
include medication and other
costs.) The range was $4.08
to $2,973.10 per day, with the
highest daily costs resulting
from complication-associated
premature explants. Because
most of the cost is incurred at
inception of therapy, the best
way to achieve cost savings is
by increasing the longevity of
the system to average the high
initial costs over a long pump life
span.9

Yeshvant A. Navalgund, MD
President and CEO
DNA Advanced Pain Treatment Center
Greensburg, Pennsylvania

Cost escalation of IT
medications with increasing
dosage or polyanalgesics
during the course of therapy
seems to be unavoidable.
Polyanalgesia, although more
costly (dual therapies average
$6.07/d and triple therapies
$10.40/d, compared with
monotherapy at $2.80/d),
is justified based on its effectiveness in restoring pain control.
Superior results are achieved when polyanalgesia is initiated
early.11

"Although it has historically been
positioned as a salvage therapy, IT
therapy is now being considered earlier
in the treatment spectrum."

COST OF THERAPY
Substantial costs associated with the IT drug delivery system
arise at the time of surgical implantation, as well as at the time of
revision (eg, pump battery depletion, catheter replacement, device
malfunction, infection). A 2015 retrospective study of 365 patients
estimated median system longevity to be 5.4 years. Based on

Table 1 provides Health Care Common Procedure Coding System
II device and drug codes; Table 2 provides Current Procedural

Table 1: Health Care Common Procedure Coding System II device and drug codes.
Device or drug

Code

Code description

Programmable pump and catheter

E0783

Infusion pump system, implantable, programmable (includes
all components)

Programmable pump only (replacement)

E0786

Implantable programmable infusion pump, replacement (does
not include implantable catheter)

Intraspinal implantable catheter only

E0785

Implantable intraspinal catheter used with implantable
infusion pump, replacement

Preservative-free morphine sulfate sterile solution

J2274

Injection, morphine sulfate, preservative free for epidural or
intrathecal use, 10 mg

Anesthetic drug administered intravenously

J7799

Not otherwise classified drugs, other than inhalation drugs,
administered through durable medical equipment

Refill kit

A4220

Refill kit for implantable infusion pump

30

American Society of Regional Anesthesia and Pain Medicine
2018



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