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Date Printed: October 17, 2017: 04:17 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 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. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-E0000-10

Original Effective Date: 06/15/00

Reviewed: 10/25/12

Revised: 01/01/17

Subject: External Infusion Pumps (non-insulin)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

External infusion pumps (EIP) are devices used to provide continuous ambulatory drug infusion therapy over an extended period of time. An EIP may also be referred to as an external pump, ambulatory pump, or mini-infuser. A catheter is connected from the pump to the patient’s access at the desired delivery site.

Routes of drug administration using external infusion pumps include intravenous, intra-arterial, subcutaneous and intra-peritoneal. The EIP is battery powered, and drug reservoir refilling is non-invasive.

There are hundreds of various models of external infusion pumps, most of which have been approved for marketing by the Food and Drug Administration (FDA) through a 501(K) pre-notification application.

POSITION STATEMENT:

External infusion pumps:

Rental of an external ambulatory infusion pump meets the definition of medical necessity when used to deliver an FDA-approved drug for an appropriate indication via an appropriate route:

Examples of indications for which an external ambulatory infusion pump may be medically necessary include, but are not limited to the following:

BILLING/CODING INFORMATION:

HCPCS Coding:

E0779

Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater

E0780

Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours

E0781

Ambulatory infusion pump with administrative equipment, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient.

E0791

Parenteral infusion pump, stationary, single or multichannel

K0455

Infusion pump used for uninterrupted parenteral administration of medication, (e.g., epoprostenol or treprostinol)

HCPCS codes for supplies for external infusion pumps:

A4220

Refill kit for implantable infusion pump (1 kit, per month)

A4221

Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately)

A4222

Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)

K0552

Supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, treatment plan, laboratory studies and medications.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Laboratory studies

26436-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

REIMBURSEMENT INFORMATION:

Reimbursement for supplies used with external infusion pumps is as follows:

OR

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Infusion Pumps (280.14) located at cms.gov.

The following Durable Medical Equipment Regional Carrier (DMERC) Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: External Infusion Pumps (L11555) located at cgsmedicare.com.

DEFINITIONS:

Intra-arterial: an injection made into an artery.

Intractable pain: chronic pain that is not relieved by usual medical or surgical measures.

Intraperitoneal: injection into the lining of the peritoneal cavity.

Intravenous: an injection made into a vein.

Subcutaneous: beneath the skin or dermal layer.

RELATED GUIDELINES:

Continuous Monitoring of Glucose in the Interstitial Fluid, 01-99000-03
Hyperalimentation, 09-A4000-04

Enteral Formulae, 09-A4000-61

External Insulin Infusion Pumps and Supplies, 09-E0000-11

Intrathecal Drug Therapy for Long-Term Pain Management, 09-J1000-31

OTHER:

The patient controlled analgesia (PCA) pump, a device used to allow the patient to self administer intravenous analgesic agents for post-operative and intractable pain, is covered when used in the acute care, inpatient setting.

REFERENCES:

  1. American Medical Association CPT Coding (current edition).
  2. Blue Cross Blue Shield Association 1989 TEC Evaluations, p. 59.
  3. Blue Cross Blue Shield Association Medical Policy 1.01.08, External Infusion Pumps, 04/29/03.
  4. Centers for Medicare & Medicaid Services, Medicare Local Coverage Determinations- L11555 Infusion Pumps (updated 08/05/11). (Accessed 10/02/12).
  5. Centers for Medicare & Medicaid Services, Medicare National Coverage Determinations- Publication 100-3, Section 280.14 Durable Medical Equipment External Infusion Pumps (updated 12/17/04).
  6. Medicare Coverage Issues Manual (CIM 60-14), 04/29/03.
  7. Medicare Coverage Issues Manual (CIM 60-14).
  8. Medicare Region C DMERC Medical Policy, External Infusion Pumps, 01/01/09.
  9. North GBU Regional Quality Management Committee Meeting, 02/24/00.
  10. St. Anthony’s ICD-9-CM Code Book (current edition).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/25/12.

GUIDELINE UPDATE INFORMATION:

06/15/00

New Medical Coverage Guideline.

08/23/01

MCG reviewed. No changes.

10/01/02

Local codes removed.

02/15/03

Reviewed; remove investigational statement regarding external infusion pumps used to administer vancomycin.

02/15/04

Reviewed; no change in coverage statement.

10/15/06

Revised to add investigational statement regarding combination glucose monitor and insulin pump systems; updated Related Guidelines section.

11/15/06

Revised to add reimbursement information regarding supplies.

02/15/07

Revision to coverage criteria for external insulin infusion pumps; added ICD-9 diagnosis codes for gestational diabetes.

06/15/07

Reformatted guideline; updated references.

04/15/08

Revised to update coding and reimbursement sections.

04/20/09

Unscheduled review. Revision due to creation of separate guideline for external insulin infusion pumps. Deleted ICD 9 codes 250.00 – 250.93 and 648.80 – 648.84. Deleted HCPCS codes E0784, A4230, A4231, A4232, and A9247. Update references. Delete investigational statement for integrated insulin infusion pumps and glucose monitors. Revised title of guideline adding the term non-insulin.

03/15/11

Revision; formatting changes.

09/15/11

Revision; formatting changes.

11/15/12

Revision; revised description and position statement. Updated references and reformatted guideline.

05/11/14

Revision: Program Exceptions section updated.

01/01/17

Annual CPT/HCPCS update. Revised A4221 and K0552 descriptors.

Date Printed: October 17, 2017: 04:17 PM