November 5, 2012

There continues to be considerable confusion as to which post operative pain management services are reimbursable and the criteria for ensuring that payment for them can be consistently obtained. Part of the issue has to do with the different modes of acute pain management currently being used across the country, but another point of confusion pertains to the provider categories for each type of service. While individual payor policies may vary, the essential parameters are quite consistent across all jurisdictions.  Irrespective of what a particular group’s billing practices have been historically, it is a good time to reexamine previous assumptions and review current guidelines. The fact that a given payor has not questioned charges for a particular service historically is no guarantee that payments were received legitimately or that a subsequent audit might not uncover a significant overpayment. It should be noted that contract terms can be misleading; and all terms must be evaluated by a qualified expert to determine what services are payable and under what conditions. Many payor contracts, for example, describe what services are payable in one section and who may provide them in another. Under no circumstances, however, would it be appropriate for anesthesiologists or CRNAs to bill for post-operative pain management services provided by non-qualified providers or RNs employed by the facility.

From a clinical perspective there are three common approaches to acute pain management: the use of an intravenous infusion as might be connected to a PCA pump; a single-shot injection of a long-acting agent such as Duramorph; and the insertion of a catheter that can be continuously infused for a period of days post-operatively. Each scenario presents unique opportunities to enhance the quality of patient care.

As a general premise for any discussion of acute pain management it needs to be clearly understood that the global surgical fee includes an allowance for post-operative pain management. In other words payment has already been allocated to the surgeon to provide usual and customary post-op pain management. This explains the standard compliance recommendation that any documentation of either nerve blocks or post-operative rounding should include a note that the services are being provided at the request of the surgeon. While it is true that there are no cases of a payor having exercised its option to carve out a portion of the surgeon’s global fee when an anesthesia group provides acute pain management, it is always a possibility.

With regard to intravenous pain management modalities, HCFA (the predecessor to CMS) clearly determined this is primarily the responsibility of nursing and not a reimbursable service for anesthesiologists in a clarification of RBRVS guidelines in 1994. Neither the initial evaluation of the patient’s pain needs nor any subsequent follow-up should be billed on a routine basis. The exception to this would be individual cases of intractable or unmanageable pain that would require an assessment by a pain management specialist. When such evaluations are requested by the surgeon they can be billed as inpatient consults (99251, 99252 or 99253) depending on the severity of the patient’s symptoms, however, it is important to note that this pertains only to non-Medicare patients. (Medicare intermediaries no longer recognize the distinction between visit and consult codes.)  Under no circumstances should an anesthesia practice make it a practice to see and evaluate all PCA patients.

The use of Duramorph for purposes of post-operative pain management presents two specific billing options. If the initial injection was not part of a regional anesthesia plan then it can be billed as a separate procedure using code 62311. Rounding charges are appropriate after midnight of the day of surgery and each day thereafter, and would be billed using subsequent hospital visit codes (99231, 99232 or 99233), again depending upon the severity of the patient’s symptoms. Providers are also reminded that the documentation requirements for the use of such Evaluation and Management codes (E&M) must conform to CPT guidelines and include a description of the history, physical examination and medical decision-making. Typically these services must be provided by a physician unless specifically allowed by state law and hospital by-laws.

The use of catheters for post-operative pain management is becoming more popular. Here we have to distinguish between the use of epidural catheters and specific nerve catheters such as interscalene, femoral or sciatic catheters. Some payors may also make a distinction between a catheter used for surgical pain management versus obstetric analgesia. There is a particular CPT code for the placement of each type of catheter and the same provision cited above applies that if the catheter served as the primary mode of anesthesia it is not separately billable. For follow-up care for epidural catheters code 01996 is the only appropriate choice.  This code has three specific documentation requirements and the services documented must have been provided by a physician or a CRNA in the employment of the group. It is not appropriate to bill for the services of RNs, especially not those employed by a hospital. The use of code 01996 requires that the catheter still be in place, that the physician or CRNA who saw the patient document when he or she saw the patient and some evidence of an evaluation in the form of a note that could be retrieved in the case of an audit. Code 01996 should not be used for daily management for non-epidural catheters; rounding of these patients should be billed with subsequent hospital visit codes.

While there are many good and valid reasons for an anesthesia practice to provide comprehensive acute pain management services, the economics of such a commitment do not always justify the commitment. Some surgeons are not as disposed to having anesthesiologists or CRNAs perform nerve blocks if these activities delay the start of the case. Generally, though, the aggressive use of post operative analgesia is perceived to enhance patient satisfaction with the surgical experience.  Any practice considering a modification to its existing level of coverage is well advised to evaluate the manpower requirements of such a service, to assess the potential impact on turn-over times,  to carefully review all payor contracts for limitations and stipulations pertaining to acute pain management services and to prepare or have prepared a financial pro forma for the service.   

It is not uncommon for practices to revisit decisions made to provide particular lines of service that were made in a time of different circumstances and payor guidelines.  If, as you reassess the service lines provided by your practice, you identify potential non-compliance, we recommend your first contact be that of legal counsel.

The use of acute pain management techniques is considered a significant value added service by the administrations of hospitals where groups provide them consistently. It is always good for anesthesia practices to explore ways to enhance their value proposition. In these times of declining payments for professional services it is always important to remain vigilant for appropriate revenue opportunities. The challenge and the opportunity of acute pain is to balance the net revenue potential with the increased risk of potential compliance audit. This should never be interpreted as a reason not to pursue a line of business, just a reminder that it should be done carefully and with due diligence.

With best wishes,

Tony Mira
President and CEO