TrailBlazer Health Enterprises®

EDUCATION MAKES THE DIFFERENCE

Part B Drugs Used in an Implantable Infusion Pump

Code J7799KD – NOC Drugs, Other Than Inhalation Drugs, Administered Through DME

Effective immediately, compounded drugs used in an implantable infusion pump must be

billed using Not Otherwise Classified (NOC) code J7799KD, whether a single drug or a
combination of drugs is administered. Some compounded drug descriptions are similar to
Average Sales Price (ASP) HCPCS codes (e.g., code J2275 for preservative-free non-
compounded morphine). Do not use these codes when submitting claims for reimbursement.
(Note: The ASP drug files are not used in pricing compounded drugs.) The claim must be
filed with code J7799KD.

Refer to the Local Coverage Determination (LCD), “Implantable Infusion Pump,” for coverage
indications for drugs administered through an implanted infusion pump.

Note: Opioid drugs used for pain management and baclofen used for spasticity have different
limited coverage. View the LCD Web page at:

http://www.trailblazerhealth.com/Tools/LCDs.aspx?DomainID=1

Coding Guidelines
 Compounded drugs must be billed with J7799KD. This includes single-drug and
multiple-drug combinations.
 Covered single-drug or a combination of drugs should be billed on a single detail line
with code J7799KD and a quantity of one. Two exceptions are explained below.*
 The ICD-9-CM code used on each detail line must represent the condition treated by
the drug(s) billed on that detail line.
 Drug dosages used in narrative description must be mcgs or mgs only. Do not use
ugs.
 The name of the drug(s) and dosage(s) administered into the pump must be indicated
for Part B claims in Item 19 of the CMS-1500 claim form or the electronic equivalent of
the claim.
 Non-compounded baclofen (*J0475KD) is routinely used as a single-drug therapy for
spasticity. It is not routinely used with other intrathecal drug combinations for pain
management. Medicare does not provide reimbursement for non-compounded
baclofen combined with any other intrathecal drugs.
 Baclofen (non-compounded and compounded) is indicated for use in the treatment of
spasticity. Baclofen has a separate list of covered diagnoses in the associated LCD.
 Compounded baclofen (*J7799KD) must be billed on a separate detail line of the
claim from any other J7799KD pain management drugs in the infusion pump.

Published August 2010

Medical Review
 Compounded baclofen and pain management drugs do not have the same coverage
requirements. For payment to occur, the ICD-9-CM code on the detail line of the
compounded baclofen must be related to a diagnosis of spasticity (see LCD for
diagnosis list).
 Patients treated with Intrathecal Therapy (IT) of ziconotide (Prialt) should not receive
opiates in their therapy. Combination of ziconotide with intrathecal opiates has not
been studied in placebo clinical trials and is not recommended per FDA-approved
package insert. Medicare will not allow payment for this drug combination.

The following are narrative description examples:

o Fentanyl 1,000 mcg/hydromorphone 10 mg/bupivicaine 10 mg.
Or,
o Baclofen 4,000 mcg (on one claim line).
And,
o Morphine 20 mg/bupivicaine 6 (on a second claim line).

Do not list the drug separately from the dosage, as in the example below:
o Morphine-bupivicaine-baclofen-sufentanil 20 mg/6 mg/4 mg/5 mcg.

Do not include baclofen on the same claim line as other drugs in the pump as in the
example below:
o Morphine 20 mg, bupivicaine 6 mg, baclofen 4 mg, sufentanil 5 mcg.

Reimbursement
An invoice is not required for payment of the compounded drugs listed in the Compounded
Drug Fee Schedule below. The following drug reimbursement is based on the concentration
used. Reimbursement for drugs administered in a combination will be based on the combined
allowance of each of the drug dosages.

Example:
 Baclofen 4,000 mcg (with a covered diagnosis for spasticity – on one claim line).
And,
 Morphine 20 mg/bupivicaine 6 mg (with a coverage diagnosis – on a second claim
line).

Will be priced as follows:

 Baclofen 4,000 mcg – $125 allowed.
 Morphine up to 45 mg – $40 allowed.
 Bupivicaine up to 7.5 mg – $10 allowed.
 The total allowed amount for this combination of drugs ($40 + $10 + $125) is $175.

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 Compounded Drug Fee Schedule
Drug Name Concentrations Reimbursement*
Baclofen Up to 2,000 mcg (2 mg) $60
Baclofen 2,001 to 4,000 mcg (4 mg) $125
Baclofen Over 4,000 mcg (4 mg) $150
Bupivicaine Up to 7.5 mg $10
Bupivicaine Over 7.5 mg $20
Clonidine Up to 2 mg $48
Clonidine Over 2 mg $88
Fentanyl Up to 1,000 mcg (1 mg) $55
Fentanyl 1,001 to 2,500 mcg (2.5 mg) $115
Fentanyl 2,501 to 5,000 mcg (5 mg) $200
Fentanyl Over 5,000 mcg $320
Hydromorphone (Dilaudid®) Up to 45 mg $90
Hydromorphone (Dilaudid®) Over 45 mg $110
Morphine Up to 45 mg $40
Morphine Over 45 mg $60
$650.70 (effective April 1,
2009)
Prialt 100 mcg $633 (after July 1, 2006)
$622 (prior to July 1, 2006)
$1,301.40 (effective April 1,
Prialt 200 mcg 2009)
$1266
$3,254 (effective April 1,
Prialt 500 mcg 2009)
$3,165
Sufentanil Up to 50 mcg (0.05 mg) $200
Sufentanil Up to 100 mcg (0.1 mg) $350
Up to 200 mcg (0.2 mg) and $425 (maximum allowable
Sufentanil
above for sufentanil)
If the cost to the physician is significantly greater than the above reimbursement, a valid
invoice may be supplied with a redetermination request. It must indicate the physician made
a good faith effort to purchase the drug at a reasonable cost.

Note: Reimbursement is based on the amount of product included in the compounded drug
(concentration) not the size of the pump (e.g., 20 ml versus 40 ml).
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