For a complete overview of coding for PRIALT, please download a copy of the Reimbursement Guide.

Physician Office Billing Codes*

J2278	Injection, Ziconotide, 1 Microgram
A4220*	Refill Kit
95990	Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular)
95991	Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), administered by physician
62367	Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming
62368	Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming
99211-99215	Office or other outpatient visit
99354 or 99355	Prolonged service, office

Click here to download CPT/HCPCS billing codes in printer friendly pdf format (110kb pdf)

Hospital Billing Codes

636 Drugs/Detail Code	J2278, Injection, Ziconotide, 1 Microgram
761 Treatment Room 510 Outpatient clinic visit 920 Other diagnostic services 360 Operating room services	CPT 95990, Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular) CPT 95991, Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), administered by physician CPT 62367, Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status), without reprogramming
270 Medical surgical supplies	A4220, Refill kit

Click here to download hospital billing codes in printer friendly pdf format (110kb pdf)

Special Notes:
A: CPT codes 95990/95991 and 62368 may be reported with HCPCS J2278. Other HCPCS codes may be required by the payer.

B: When billing Medicare outside of the hospital outpatient setting, it may be necessary to add a ‘KD’ modifier to the J code on a CMS-1500 Claim Form to indicate that the drug was administered using an infusion device†

C: It may not be appropriate to bill for an additional evaluation and management code unless a separate and identifiable service has been performed in addition to the pump refill and pump reprogramming procedures. Please check individual payer guidelines regarding the use of codes 99211-99215 or 99354-99355 in addition to the full descriptors for each code as provided in the most recent Current Procedural Terminology (CPT) guidelines.

* The refill kit should be billed for all payers for consistent billing practice and for future procedure code payment calculation, even though Medicare does not reimburse for it at this time.

†CMS Manual System, Publication 100-4, Medicare Claims Processing Manual, Transmittal 54, Change Request 3022, New Basis for Medicare Drug Payment Amounts Under Part B, addresses the payment of claims for infusion drugs furnished through an implanted DME infusion pump, for dates of service on or after January 1, 2004, must be identified using the “KD” modifier. The payment limit for these drugs shall be 95 percent of the AWP.

Note: Many payers require providers to report the drug National Drug Code (NDC) number as supporting documentation when billing with Miscellaneous HCPCS codes, such as J3490 for PRIALT. In addition to the procedure codes and HCPCS drug code, non-Medicare payers may allow providers to code and bill for the infusion pump refill kit. (A4220). See attached sample claim forms for examples.

Providers should contact the Elan Pain Information Center at 1-888-PRIALT-1  (1-888-774-2581) or consult with individual payers for local coverage information and reimbursement policies.