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WHERE SHOULD ANESTHESIA AND PAIN MEDICINE PRACTICES LOOK FOR MEDICAL NECESSITY POLICIES

August 24, 2009

You wonder whether your patient’s insurance will cover monitored anesthesia care (MAC) for an upper GI endoscopy, or for a pain medicine procedure. For that matter, how many pain injections will the payer cover? You have heard that many anesthesiologists are successfully billing for the pre-operative history and physical and you would like to know whether they know something that you don’t.

The answers to questions like these are usually to be found in the payer’s medical review or medical necessity policies. The payers all have them, and they should make them readily available to you, particularly if you participate in their health plans. The payers all have medical directors, too, and it is these physicians who are the initiators and champions of most medical policies. Depending on the payer, the medical director may be easily accessible and may be willing to amend policies. He or she is unlikely to be an anesthesiologist, in our experience. The anesthesiologist who has made friends with the medical director before a controversy arises will be in the best position to negotiate. If no current policy covers the procedure that the payer has denied, creating an alliance with the medical director may also be useful.

Medicare’s National and Local Coverage Determinations

Medicare also gives a significant role to medical directors, although the policy-making process is much more formal and structured within CMS, which spends more than $2 billion per year on anesthesiology services alone. To begin with, the Social Security Act provides that Medicare only covers items and services that are “reasonable and necessary” for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) are the major vehicles through which the Centers for Medicare and Medicaid Services (CMS) publish its medical necessity policies.

On the national level, NCDs are made through an evidence-based process, with opportunities for public participation. In some cases, CMS' own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). The statute was amended by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MIPPA) to require that the Agency publish an annual report listing the national coverage determinations made in the previous year. All contractor LCDs shall be listed in the Medicare Coverage Database. An index search for NCDs containing the word “anesthesia” reveals just the following two documents:

NCD Section   NCD Title
20.8.3
  ANESTHESIA in Cardiac Pacemaker Surgery
10.1
  Use of Visual Tests Prior to and General ANESTHESIA during Cataract Surgery


The pacemaker NCD dates from 1988 and provides only that “Covered use of general or monitored anesthesia during transvenous cardiac pacemaker surgery on a case-by-case basis when adequate documentation of medical necessity is provided.”

In the absence of a national coverage policy, a medical service may be covered at the discretion of the Medicare contractors based on an LCD.

An LCD is defined by statute as a decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary). Many readers still remember the term “Local Medical Review Policies” (LMRPs). By January 2006, all existing LMRPs had been converted into LCDs, the content of which is supposed to be limited to "reasonable and necessary" information. “Articles” containing other coverage requirements, coding instructions and miscellaneous information, like the LCDs, must be posted both on the carrier or Medicare Administrative Contractor (MAC) website and on the Medicare Coverage Database website. An example of an article is the list of anesthesia modifiers recently finalized by Wisconsin Physicians Service Corporation, the MAC – Part B for Missouri, Iowa, Kansas and Nebraska

It is worth checking your own MAC’s site on at least the following three occasions:

  1. You are surprised by a Explanation of Medicare Benefits that denies payment, on medical necessity grounds, for a service you provided, or because the MAC doesn’t pay for more than n number of pain medicine injections;
  2. You want to make sure that your documentation meets the MAC’s requirements, and
  3. You want to find out whether there are any draft LCDs that are still open for public comment.


One of the best-known services addressed by LCDs is Monitored Anesthesia Care. Over the last 15 years or more, Medicare carriers have repeatedly attempted to circumscribe the surgical procedures for which monitored anesthesia care is payable. TrailBlazer, the MAC – Part B for Virginia and a number of other states across the country, uses the venerable A/B list, where medical necessity is assumed for the anesthesia codes on List A and must be demonstrated for the codes on List B. A long third list, this one of ICD-9 diagnosis codes, indicates the patient conditions that will support medical necessity, e.g. septicemia (ICD-9 codes 038.0–038.9) and anxiety (ICD-9 300.00-300.10) – as long as “the patient’s severe anxiety, hysteria or panic attack condition is supported by the need for and responses to sedative medication(s).” TrailBlazer last modified its MAC LCDs in late 2008 when it added and otherwise updated ICD-9 codes.

These LCDS also illustrate their value in making sure that your documentation is adequate. For example, “Hemorrhage of gastrointestinal tract” is qualified by the following note: "Use of the diagnosis code above must be representative of massive gastrointestinal bleeding (e.g., more than 500 cc. of acute blood loss)." Clearly, the medical record must reflect the loss of at least half a liter of blood. Trailblazer gives further indications of documentation requirements in the following section of the LCD:

Additional diagnoses that do not have a fully descriptive ICD-9-CM code are listed below. By using the diagnosis code(s) listed, the medical records must reflect the conditions as described.

  • For combative patients, use ICD-9-CM code 312.9.
  • For patients with low pain thresholds or who suffer severe pain, use ICD-9-CM code 997.00.
  • For intraoperative expansion of procedure, use ICD-9-CM code 998.9.
  • For any condition in a pediatric patient, Medicare eligible and younger than 12 years of age, use ICD-9-CM code 999.9.


If MAC is used for these reasons, clinical records must be available upon request that justify the need for MAC.

On the pain management side, many readers have already encountered the comprehensive policy recently adopted by National Government Services. The discussion of trigger point injections in this LCD is a good guide to documenting medical necessity:

Indications and Limitations for Specific Types of Injections

TRIGGER POINT INJECTIONS
….

Indications:

The diagnosis of trigger points requires a detailed history and thorough physical examination. The following clinical features are present most consistently, and are helpful in making the diagnosis:

 History of onset of the painful condition, and its presumed cause (injury, sprain, etc.);

Distribution pattern of pain consistent with the referral pattern of the trigger points;

Restriction of range of motion with increased sensitivity to stretch;

Muscular deconditioning in the affected area;

Focal tenderness of a trigger point;

Palpable taut band of muscle in which trigger point is located;

Local taut response to snapping palpation or needle insertion; and

Reproduction of referred pain pattern upon stimulation of the trigger point.

The goal is to treat the cause of the pain and not just the symptom of pain. Other treatment modalities include:

Pharmacologic treatment including analgesics and medications to induce sleep and relax muscles (i.e. antidepressants, neuroleptics, or non steroidal anti-inflammatory drugs); and

Nonpharmacologic treatment modalities (i.e., osteopathic manual medicine techniques, massage, ultrasonography, application of heat or ice, transcutaneous electrical nerve stimulation, Spray and Stretch technique); and

For trigger points in the acute state of formation (before additional pathologic changes develop), effective treatment may be delivered through physical therapy.

After myofascial pain syndrome is established as described above, trigger point injection may be indicated when noninvasive medical management is not successful or as first line treatment.

Additionally, trigger point injection is indicated when the movement of a joint is mechanically blocked as is the case of the coccygeus muscle.

Limitations:

Only one trigger point injection procedure (CPT codes 20552 or 20553) should be reported on any particular day, no matter how many sites or regions are injected.

The local anesthetic administered in conjunction with trigger point injections is included in the practice expense for these procedures.

Trigger point injections used on a routine basis, e.g., on a regular periodic and continuous basis, for patients with chronic non-malignant pain syndromes are not considered medically necessary.

In addition to listing the patient conditions that will support medical necessity, this section of the LCD offers the following guidance:

  1. If another treatment modality has already been tried without success, you should record that fact in the medical record.
  2. Note it down if the movement of a joint is mechanically blocked.
  3. Do not submit more than one claim containing the CPT code for the procedure per day.
  4. If you are performing trigger point injections on an ongoing, routine basis, document that they are relieving the patient’s pain in a way that cannot be better accomplished by some other therapy.


And that is just the section on trigger point injections. The LCD also covers injections into tendon sheaths, ligaments, ganglion cysts, tarsal or carpal tunnel; epidural and intrathecal injections; transforaminal epidural injections; paravertebral facet joint/nerve block injections; paravertebral facet joint/nerve block denervation; sacroiliac joint injections; and other procedures for post-operative pain management.

To find out whether any LCDs apply to your practice, check the state index on the Medicare Coverage Database web page.


Contractor Consultation with Practicing Physicians

These highly prescriptive medical policies are developed to a considerable extent by physicians. Anesthesiologists and pain specialists, like other physicians, want to know whether the policies reflect input from practicing members of their specialty.

Contractors develop LCDs by considering medical literature, the advice of local medical societies and medical consultants, public comments, and comments from the provider community.

The Medicare Program Integrity Manual ,Chapter 13 describes the circumstances when a Contractor must or may develop an LCD; the factors that Contractors must consider in writing LCDs, and the procedures to be followed to ensure that the practicing physician community is heard.

Of particular interest here is the Carrier Advisory Committee (CAC) that each Contractor Medical Director (CMD) is required to convene in each state within his or her territory (with certain exceptions). There should be a representative and an alternate from each of the 24 major specialties (at least). One of the physicians on the CAC will serve as co-chair together with the carrier medical director. The CMD must convene the CAC not fewer than three times per year; “carriers work with the State medical society and committee members to select a meeting location that will optimize participation of physician committee members.” All new or revised, more restrictive LCDs must be published for comment for at least 45 days. After all the comments have been collected, the Contractor shall provide a minimum notice period of 45 calendar days on the draft LCD before a final version goes into effect and is posted on the website.

The CAC is not the only source of community medical opinion for the CMD, who is also required to seek comments from “groups of health professionals and provider organizations that may be affected by the LCD; representatives of relevant specialty societies,” and other CMDs within the region. In our experience, the CMDs informally listen to the physicians with whom they have the best relationships, whether those physicians are the most knowledgeable members of or are even nominated by their specialty societies.

The community practitioners or national specialty society physicians have a very important role to play. The CAC members are charged with disseminating draft LCDs among their colleagues and bringing the various opinions back to the CAC, Beginning in the 1990s, the American Society of Anesthesiologists opened up relationships with many CMDs and was able to influence policies such as those defining the circumstances under which anesthesia for screening colonoscopies is payable, for instance. ASA members also have a history of working with their CMDs to obtain clarifications of payment policies which would now be issued in the form of “articles.”

If you want to know who represents you on your local CAC – or if you want an indirect or (why not?) a direct voice on that committee -- you should begin with both the CMD and with your state anesthesiology society. They will know who the incumbent anesthesiologists are and they will be indispensable supporters if you seek membership on the CAC yourself.

We hope that the information provided in this Alert is useful to you.

With all the best wishes,

Tony Mira
President and CEO