Billing Guidelines

Got it ✅ — here’s the full text from the CMS Billing Guideline for C9806 and Catheter Placement under the NO PAIN Act (2025) extracted as-is so you can drop it straight onto a webpage:

CMS Billing Guideline for C9806 and Catheter Placement under the NO PAIN Act (2025)

Background

The NO PAIN Act, effective January 1, 2025, requires Medicare to reimburse separately for non-opioid pain management techniques used in outpatient surgical settings (ASC/HOPD), including:

• Infusion pump insertion (C9806)

• Pre-operative catheter placement (e.g., CPT 64416, 64417, 64418)

Key condition: These procedures must occur before the primary surgery to avoid being bundled into the global surgical payment.

Billing Overview

Proper Billing Steps

Verify Patient Eligibility

• Must be Medicare Part B (or Advantage)
• Procedure in ASC (POS 24) or HOPD (POS 22)
• Non-opioid pain management must be documented

Document Services Properly

• Catheter placement (64416–64418) must be:
• Clearly noted as pre-operative
• Supported with time stamps
• Linked to diagnosis (e.g., G89.18 – postprocedural pain)
• C9806 documentation should include:
• Infusion pump placement
• Purpose for post-op non-opioid pain control
• Confirmation pump was used

Use Appropriate Codes

• C9806 – Non-intrathecal infusion pump insertion
• 64416–64418 – Pre-op continuous nerve block catheter placement
• G89.18 or similar for post-op pain

Reimbursement Expectations

• C9806: ~$335–$375 (depending on Pump ASP, MAC/locality)

• 64416–64418: $600–$1000 depending on MAC/locality

• All are separately payable if timing/documentation meets criteria

Modifier Usage

• No modifiers are required by CMS for C9806 or catheter codes under the NO PAIN Act.

• However, some Medicare Advantage plans may require:

  • -59 (Distinct procedural service)

  • RT/LT (if applicable by nerve location)

• Always review MAC and payer-specific edits.

Denial Management

If C9806 or catheter codes are denied, take the following steps:

Review denial reason (e.g., bundled, not medically necessary).

Resubmit with full documentation, including:

• Time-stamped anesthesia record
• Operative note
• Description of non-opioid post-op pain plan

Include a short appeal letter citing the NO PAIN Act (Section 9001, Consolidated Appropriations Act, 2021) and supporting the clinical necessity.

Appeal Medicare Advantage denials through their plan process.

Frequently Asked Questions (Q&A)

Q: Can I bill C9806 and 64416 on the same date of service?
Yes, if the catheter is placed pre-op and the pump is inserted post-op. Ensure both are documented separately and linked to appropriate diagnosis codes.

Q: Should I bill Medicare Advantage plans?
Yes, Medicare Advantage (Replacement) plans fall under the NO PAIN Act.

• But coverage may lag behind CMS timelines.

• Be prepared to appeal and submit documentation supporting eligibility under the NO PAIN Act.

Q: What happens if my claim for C9806 or 64416 is denied?
Denials usually stem from timing issues, bundling edits, or lack of documentation. Submit an appeal with detailed records showing catheter placement was before surgery and infusion pump was used for non-opioid post-op pain control.

Q: Can I place the catheter after surgery?
No – if placed after or during surgery, the service is considered bundled and not separately reimbursable.

Summary Checklist

• ✅ C9806 – Bill for infusion pump

• ✅ 64416–64418 – Bill if catheter placed before incision

• ✅ Use G89.18 or relevant pain diagnosis

• ✅ No modifiers required (unless payer demands)

• ✅ Bill both Medicare and Medicare Advantage

• ✅ Appeal if denied — cite NO PAIN Act

Comfort, safety, and mobility — that’s what the ambIT Pump brings to every recovery.