Health Information Management

Get the facts on coding for non-biodegradeable drug delivery implants

JustCoding News: Outpatient, February 22, 2012

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

by Lori-Lynne A. Webb, CPC, CCS-P, CCP, COBGC, CHDA

Drug delivery implants are designed to provide active pharmaceuticals to a targeted area in into the patient’s body for a certain length of time site.

Coders continue to struggle with coding for drug delivery implants. Although CPT® did not make many changes to these codes for 2012, coders must understand how to correctly report drug delivery implant codes. In addition, coders also need to understand what the physician must document in order for coders to report these services correctly.

CPT denotes these codes:

  • 11981 – Insertion, non-biodegradeable drug delivery implant
  • 11982 – Removal, non-biodegradeable drug delivery implant
  • 11983 – Removal with reinsertion, non-biodegradeable drug delivery implant

These codes appear very straightforward for coders to use, but some implants used in surgery are now biodegradeable, or “absorbable” by the body. The patient’s body will not absorb a non-biodegradeable implant, and at some point in time, a physician will need to remove it from the body.

Uses of drug delivery implants
In the orthopedic specialty, physicians commonly use drug delivery implants. The implants range in size from a tiny ”antibiotic bead” to a total knee prosthesis spacer made with antibiotic-impregnated cement. In some cases the physician will place a drug delivery implant with pain medication during surgery to lessen post-operative pain, but then will remove the implant in the office as part of the post-operative care services.

Orthopedics is not the only specialty to use non-biodegradeable implants at the time of surgery. Ophthalmologists use these types of implants for ocular disease treatment and surgical treatment enhancement options. Intravitreal, subconjunctival, and peri-ocular routes of administration for these implants are quickly becoming popular among ophthalmic providers and their patients.

Due to the size and constraints of the eye, an ophthalmologist can use a non-biodegradeable implant reservoir or a sub-conjunctival, intrascleral, or intravitreal implant to deliver a drug or medication directly to targeted areas within the eye and/or the surrounding eye structures.

Non-biodegradeable implants offer the advantage of a constant or steady controlled release of a drug or medication for a long or extended period of time, ranging from days to years. The disadvantage is at some time the physician must either remove the implant or remove and reinsert an implant.

Many of the new implanted non-biodegradeable delivery systems use a nonreactive outer shell, such as silicon or ethylene vinyl acetate (EVA) to house the drugs such as antibiotics, anti-inflammatories (steroids), and antivirals. These drugs can look like small beads, pellets, rods, slivers, or spacers.

Some non-biodegradeable implants used in orthopedic surgeries are made of cement or bone putty that has been impregnanted with the drug.

Common coding mistakes
As of January 1, CPT deleted codes 11971 and 11975, which were used for designation of insertion/removal or combination insert/removal of implantable contraceptive capsules. Coders should now report codes 11976 (removal of Norplant), 11981, or 11982 for this new type of contraceptive device.
As a coder, do not confuse codes 11981–11983 with an insertion of a pain-pump type of supply. Pain pumps are often used in orthopedics and spinal surgery, but CPT has designated codes 62350–62370 for drug infusion pumps that are external, implantable, intrathecal, or epidural-based within spinal and nervous system surgeries.

Coders often mistakenly believe that they can simply use an unlisted CPT code, such as 49999 (unlisted procedure, abdomen, peritoneum and omentum) for billing purposes., Code 49999 is often used to report the ON-Q pain pump for post-procedure pain management in general surgery. If you choose to use an unlisted CPT code, be prepared to document why the unlisted code is a better choice than using a CPT code designated for the use of a drug delivery implant.

Documentation tips
Review the coding guidelines thoroughly when reporting the insertion, removal, or combination of the drug delivery implant system at the time of surgery: Consider the following tips:

  • Assess the operative note to verify the implant is non-biodegradeable.
  • Report the insertion and/or removal of the non-biodegradable implant separately. . (if the supply is a biodegradeable implant, its insertion and removal is included in the primary surgical code) .
  • Review the physician's operative documentation closely to ensure it clearly shows the insertion, removal, or combination of insertion and removal at the same time. The physician should always separately define this in the operative note.
  • Review which modifiers you may use at the time of the surgery). Verify if you are within a global period from a previous surgery to ensure correct use of modifier -51 (multiple procedures), modifier -58 (staged or related procedure or service by the same physician during the postoperative period), modifier -59 (distinct procedural service), and modifier -22 (increased procedural service).
  • Code the supply itself with a HCPCS code, in addition to the surgical CPT code if the physician is performing the surgery in his or her office surgical room. Usually, the manufacturers will supply you with the appropriate HCPCS code to submit. If the physician is performing the surgery in a separate hospital or outpatient facility, the facility will bill for the supply.

Documentation examples
When looking at documentation for coding these implants, coders need to find certain information. The following scenarios demonstrate good documentation examples. . The information in italics denotes the documentation you need to use codes to bill for insertion, removal, or insertion with removal. .

Example 1: Insertion of Implanon® non-biodegradeable contraceptive subcutaneous device

The patient was placed in the supine position. Her nondominant arm was placed above her head. The inner aspect of the arm was marked with a sterile pen and then cleansed with Betadine® solution. It was then injected with 1% lidocaine with epinephrine, and then the Implanon device was prepared per the package insert. It was inserted just beneath the skin, and then the transducer was removed from the subcutaneous tissues. The Implanon was readily palpable and there was minimal bleeding. A pressure dressing was placed. The patient was asked to continue with the pressure dressing for 24 hours and otherwise keep the area clean and dry.

Example 2: Orthopedic wound re-opening with insertion of an antibiotic containing bone cement

We again debrided down to bone and resected more soft bone. There was a defect between the first metatarsal and the medial cuneiform after the bone section. We noted flaking cartilage off the first and second TMT [[tarsometatarsal] joints and all the loose cartilage was removed. Palacos gentamicin containing bone cement was mixed and we used this as a cement spacer between the first metatarsal and the medial cuneiform. The wounds were then packed open with saline moistened Kerlix™ rolls. The ABDs, followed by an ACE™ wrap, was then applied over the top.

Example 3: Opthalmologic insertion of gancyclovir capsule via vitrectomy

In an attempt to control the cytomegalovirus, a long-acting capsule of the antiviral drug ganciclovir is placed into the anterior vitreous cavity during vitrectomy of the right eye. The goal is to have medication released slowly into the vitreous cavity, the retinal infection can be held in check, and vision can be preserved. The patient was wheeled to the OR table. Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine® and Marcaine® was delivered to retrobulbar area and massaged and verified. Preparation was made for 23-gauge vitrectomy, using the trocar. Inferotemporal cannula was placed 3.5 mm from the limbus and verified. The fluid was run. Then superior sclerotomies were created using the trocars, 3.5 mm from the limbus at 10 o'clock and 2 o'clock. Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps and ILM forceps, the membrane was peeled off in its entirety. The ganciclovier capsule was placed within the cavity. There were no complications. DVT precautions were in place. Re-check pt in 3 days, anticipate removal/reinsert gancyclovir capsule in 6-7 months.

Example 4: Orthopedic wound re-opening with removal and reinsertion of an antibiotic containing bone cement

We dissected down to the ankle joint and identified the methyl methacrylate spacer. Using a Hoke osteotome, we morcellized this. It was 1 large piece and we morcellized it and fragmented it into many different pieces and then one by one removed them. Following this, after we had removed all the methyl methacrylate, we then debrided the medial and lateral gutters of the talus, the fixation groove ,and the anterior and posterior ankle. We then curetted in a meticulous fashion the tibial weightbearing surface as well as the plafond. I saw no active infection present or purulence. We took soft tissue cultures superficially and deep and cultures as well. I then hand delivered these to pathology at the conclusion of the case.

The ankle joint was then lavaged with triple antibiotic solution with Pulsavac® and then we made a double mix of methyl methacrylate with both tobramycin and vancomycin. At the appropriate time, the cement was placed into the interval and we allowed it to harden. We then irrigated the wound and closed the deep tissue with 0 Vicryl™ tissue. We developed a skin flap and closed the superficial with 2-0 Vicryl and the skin with interrupted nylon suture. Sterile compressive dressing was applied, followed by a posterior plaster splint. Patient was awakened, transferred to a gurney, and taken to the recovery room in stable condition. Sponge and needle count were correct.

Editor’s note: Lori-Lynne Webb, CPC, CCS-P, CCP, is an independent consultant in Melba, ID. E-mail her at LORIWEBB@sarmc.org or webbservices.lori@gmail.com.
 



Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

Most Popular