Medtronic Product HCPCS and Outpatient Category C-Codes

1 Medtronic Product HCPCS and Outpatient Category C-Codes The following is a list of Medtronic Neurological products grouped by type of therapy. This information will be helpful when providing patient care in the hospital Outpatient setting. Neurostimulation Chronic Pain Medtronic Product Brand Name and Medtronic Level II National Hospital Outpatient Description Model No. HCPCS code1 Category C-Codes2. Synergy implantable neurostimulator 7427 E0756 C1767. and extension 7471 or 7489 C1883. Synergy Versitrel implantable neurostimulator and 7427V E0756 C1767. extension 7471 or 7489 C1883. Synergy EZ patient 7435 E0754 C1787. programmer (hand-held). Itrel 3 implantable neurostimulator and in-line 7425 E0756 C1767. connector extension 7489 C1883. Itrel 3 EZ patient programmer (hand-held) 7434A E0754 C1787. Mattrix receiver (2X4) 3272 E0757 (receiver) C1816. Mattrix transmitter kit 3210 E0758 (transmitter). Pisces Z-Quad lead kit 3890 E0752 C1778. Pisces Z-Quad compact lead kit 3891 E0752 C1778.

2 Pisces Z-Quad Plus lead kit 3892 E0752 C1778. Pisces-Quad lead kit 3487A E0752 C1778. Pisces-Quad compact lead kit 3887 E0752 C1778. Pisces-Quad Plus lead kit 3888 E0752 C1778. Pisces-Octad lead kit 3898 E0752 C1778. Specify lead kit (CPT codes for a laminectomy are 3998 E0752 C1778. classifieds as inpatient only). Resume II lead kit 3587A E0752 C1778. Resume TL lead kit 3986A E0752 C1778. SymMix lead kit 3982A E0752 C1778. On-Point peripheral nerve stimulation lead kit 3987A E0752 C1778. Activa Therapy Parkinson's disease, Tremor Medtronic Product Brand Name and Medtronic Level II National Hospital Outpatient Description Model No. HCPCS code1 Category C-Codes2. Kinetra neurostimulator and extension 7428 E0756 C1767. 7482 C1883. Soletra neurostimulator and extension 7426 E0756 C1767. 7482 C1883. Not applicable (CPT code DBS lead kit ( mm spaces) 3387-40 E0752 for DBS lead DBS lead kit ( mm spaces) 3389-40 E0752 implantation is classified as inpatient only). Access Therapy Controller 7436 E0754 C1787.

3 Access Review Therapy Controller 7438 E0754 C1787. Page 1 of 30. Drug Delivery Therapies Chronic pain, Cancer pain, and Intrathecal Baclofen Therapy Medtronic Product Brand Name and Medtronic Level II National Hospital Outpatient Description Model No. HCPCS code1 Category C-Codes2. SynchroMed EL infusion pump 862618 E0783 C1772. Programmable, 18mL. reservoir E0786(replacement). SynchroMed EL infusion pump. 8626L18 E0783 C1772. Programmable, 18mL. reservoir, and suture loops E0786(replacement). SynchroMed EL infusion pump 862610 E0783 C1772. Programmable, 10mL. reservoir E0786(replacement). SynchroMed EL infusion pump 8626L10 E0783 C1772. Programmable, 10mL. reservoir, and suture loops E0786(replacement). SynchroMed EL infusion pump, attached screened catheter access port. 862718 E0783 C1772. Programmable, 18mL. reservoir E0786(replacement). SynchroMed EL infusion pump, attached screened catheter access port. 8627L18 E0783 C1772. Programmable, 18mL. reservoir, and suture loops E0786(replacement).

4 SynchroMed EL infusion pump, attached screened catheter access port. 862710 E0783 C1772. Programmable, 10mL. reservoir E0786(replacement). SynchroMed EL infusion pump w/ filter and attached screened catheter access port. 8627L10 E0783 C1772. Programmable, 10mL. reservoir, and suture loops E0786(replacement). SynchroMed II infusion pump with filter. Programmable, provided with mesh pouch, 20 ml 863720 E0783 C1772. Reservoir E0786(replacement). SynchroMed II infusion pump with filter. Programmable, provided with mesh pouch, 40 ml 863740 E0783 C1772. Reservoir E0786(replacement). 8472-20. IsoMed infusion pump, non-programmable 8472-35 E0782 C1891. 8472-60. InDura IP intrathecal catheter 8709 E0785 (Replacement C1755. catheter only). 8731 intrathecal catheter 8731 E0785(Replacement C1755. catheter only). 8749 intrathecal catheter 8749 E0785(Replacement C1755. catheter only). Algoline intraspinal catheter 81102, 81192 E1399 C1755. Page 2 of 30. Drug Name Medtronic Level II National Hospital Outpatient Model No.

5 HCPCS code1 Category C-Codes2. Morphine Sulfate preservative-free, per 10mg N/A J2275 N/A. Floxuridine, per 500mg N/A J9200 N/A. Lioresal Intrathecal (baclofen injection). Screening ampule (50mcg) 8563s J0476 C9007. NCD 58281-0562-01. Lioresal Intrathecal Refill Kit, one ampule of 10mg/20mL (500mcg/mL) 8561 J0475 C9008. NDC 58281-0560-01. Lioresal Intrathecal Refill Kit, two ampules of 10mg/5mL (2,000 mcg/mL) 8562 J0475 C9009. NDC 58281-0561-02. Lioresal Intrathecal Refill Kit, one ampule of 40mg/20mL (2,000mcg/mL) 8564 J0475 C9009. NDC 58281-0563-01. Lioresal Intrathecal Refill Kit, two ampules of 20mg/40ml (500mcg/mL) 8565 J0475 C9008. NDC 58281-0560-02. Lioresal Intrathecal Refill Kit, two ampules of 80mg/40mL (2,000mcg/mL) 8566 J0475 C9009. NDC 58281-0563-02. Footnotes: 1 HCPCS 2004, Practice Management Information (PMIC), Los Angeles, CA 2004. 2 Federal Register, Vol. 68, No. 216, November 7, 2003, #63438. C-Codes for device categories, as they existed on December 31, 2002.

6 The use of the codes is not required and will not be enforced. Consult CMS Transmittal A-01-41, implementation date 4-1-2001, for more information about Category C-Codes . Lioresal a registered trademark of Novartis Pharmaceuticals Corporation. Please read the attached Lioresal Intrathecal (baclofen injection) disclosure. Neurological Reimbursement Assistance for: Pain, ITB and Activa Therapies (800) 292-2903. 8:00 am 5:00 pm Central Time Monday through Friday or, Note: This information is not intended to make recommendations regarding clinical practice. It is the responsibility of the provider/facility to determine appropriate coding and to understand and follow local carrier/payer coverage and coding policies. Page 3 of 30. Medtronic SynchroMed and IsoMed Infusion Systems Product technical manual and the appropriate drug labeling must be reviewed for detailed disclosure prior to use. Indications: Chronic intrathecal infusion of preservative-free morphine sulfate sterile solution in the treatment of chronic intractable pain and chronic intravascular infusion of floxuridine (FUDR) for the treatment of primary or metastatic cancer.

7 SynchroMed is also indicated for chronic intrathecal infusion of Lioresal Intrathecal (baclofen injection) for severe spasticity, chronic epidural infusion of preservative-free morphine sulfate sterile solution in the treatment of chronic intractable pain, chronic intravascular infusion of doxorubicin, cisplatin, or methotrexate for the treatment of primary or metastatic cancer, and chronic intravenous infusion of clindamycin for the treatment of osteomyelitis1. Contraindications: When infection is present2; when the pump cannot be implanted within cm (1 inch ) from the surface of the skin; when body size is not sufficient to accept pump bulk and weight; when contraindications exist related to the drug. Blood sampling through the side catheter access port is contraindicated. Warnings: Use only with approved drugs. Improper use, calculation or programming errors, or component failure may result in loss of therapeutic effect, or clinically significant or fatal drug overdose or underdose symptoms.

8 Clinically significant or fatal drug overdose may result from overpressurization of the pump reservoir, overheating of the pump during implant preparation or as a result of diathermy, improper pump preparation, improper injection of drug through the catheter access port or into the pump pocket, or failure to account for significant amounts of drug residing in the reservoir, pump tubing, catheter access port, or catheter. The effects of mixing drugs are unknown. Flow rate of the IsoMed pump may decrease or stop if drug precipitation occurs. An inflammatory mass that can result in serious neurological impairment, including paralysis, can occur at the tip of the implanted catheter. Patients on intraspinal opioid therapy should be monitored carefully at each visit for any new or changed neurological signs or symptoms. Timely treatment may minimize or avert permanent neurological injury. The effects of implanting the SynchroMed pump in patients with other implanted programmable devices are unknown.

9 Do not use if sterility has been compromised or if the use by date has expired. Do not resterilize or reuse. Precautions: Only qualified personnel should implant, fill and refill the pumps; access the catheter access ports; or program the SynchroMed pump. Follow recommended procedures. Maintain strict aseptic techniques during all procedures to prevent infection. The catheter access port does not contain a bacterial filter. Consider use of peri- and postoperative antibiotics for pump implantation and any subsequent surgical procedures. Use caution in selecting an anatomical pump site appropriate to the size and mass of the patient. Initial fill and refill volumes must not exceed levels specified in the technical manuals. Do not allow pump to stop or run dry; if therapy is discontinued, maintain minimal flow of appropriate fluid. Do not expose pumps to temperatures above 43 degrees C (110 degrees F) or below 5 degrees C (40 degrees F). Avoid exposing pump to diathermy, therapeutic radiation, lithotripsy or pressure extremes.

10 Do not implant a pump that has been dropped onto a hard surface or shows signs of damage. Follow manufacturer's instructions regarding drug preparation, dosage, and administration. FUDR should be used with added caution in patients with impaired hepatic or renal function. Systemic therapy should be considered for patients with known disease extending beyond an area capable of infusion. IsoMed pump flow rate will vary depending on factors such as body temperature, altitude, arterial pressure at the catheter tip, and solution viscosity. Advise patients of symptoms to report, activities to avoid, and the importance of keeping refill appointments. Magnetic Resonance Imaging (MRI): MRI will temporarily stop the SynchroMed pump motor and suspend drug infusion for the duration of MRI exposure. The SynchroMed pump should resume normal operation upon termination of MRI exposure. Exposure of IsoMed pumps to MRI fields of T (Tesla) has demonstrated no impact to pump performance and a limited effect on the quality of the diagnostic information.