Documentation for Post-Anesthesia Pain Blocks and Epidurals

Last spring, we alerted readers to a proposed payment policy (“Local Coverage Determination,” or “LCD”) under which Noridian Administrative Services, LLC, the Medicare Administrative Contractor (“MAC”) for nine Western states, would have denied coverage for blocks and epidurals placed pre-operatively for the management of post-operative pain.  In Proposed "Medical Necessity" Restrictions on Post-Anesthesia Pain Blocks, we criticized the proposed LCD for confusing the timing and the purpose of post-operative pain procedures and explained the process by which MACs propose, revise and finalize LCDs.  We encouraged readers to use the process, and their representatives on the Carrier Advisory Committees of practicing physicians, to speak up for patients and help prevent undue restrictions on the availability of post-operative pain management services.

Unfortunately, although Noridian quickly corrected the section of the proposed LCD on “Nerve Blockade: Somatic, Selective Nerve Root, and Epidural” that would have prevented payment to anesthesiologists for performing procedures before or during surgery for the management of post-operative pain under Medicare Part B, the carrier did not bring the section of the policy concerning hospital payment (Part A) into line.  ASA President John M. Zerwas, M.D. pointed out the inconsistency in his June 13, 2013 letter to the Noridian medical director responsible for the LCD.  The language nevertheless reappeared in the final policy that will go into effect on November 11, 2013.  It states:

For Part A

Reimbursement for the control or management of pain in the immediate postoperative period is packaged into the payment for the procedure, surgical or anesthetic-regardless of the method by which the care provider, including the anesthesiologist, decides to manage pain. Following discharge from the post-anesthesia care unit (PACU), the medically reasonable and necessary placement of regional or peripheral pain blocks or initiation of other new pain interventions or “top-up” dosing may be separately reimbursable in the outpatient setting. Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU when documentation supports the intervention.

(Emphasis added.)  The confusion as to whether pain injections performed before discharge from PACU are payable may therefore continue.  The LCD does not contain any similar timing restriction in describing the rule applicable to Part B (professional services) payment, which now provides: 

For Part B

Reimbursement for the control or management of acute pain in the immediate postoperative period is generally packaged into the payment for the surgical procedure. However, if a need for transfer of pain management is documented and ordered by the surgeon and the accepting provider documents the need for and acceptance of transfer of care, separate reimbursement may be made for the service.

For the two paragraphs quoted to makes sense when read together, it looks as though a further correction by Noridian will be necessary.  Meanwhile, anesthesiologists in the Noridian states will increase their likelihood of being paid correctly by complying with the somewhat nebulous documentation requirements that the LCD section on Part B sets forth:

• The surgeon documents the need for and orders a transfer of pain management, and
• The anesthesiologist documents the need for and acceptance of transfer of care. 

How does one comply with the first bullet point, i.e., “the surgeon documents…?”  Does that phrase mean “the surgeon personally documents…?”  Many, many anesthesia practices rely on standing surgeon’s orders or have the anesthesiologist record the surgeon’s request for post-operative analgesia.

In its statement on Reporting Postoperative Pain Procedures in Conjunction with Anesthesia, ASA indicates:  “One excellent means of portraying that the block was a postoperative analgesic is to dictate or record its conduct in the chart in a location separate from the anesthetic record.  When documenting, it is important to discuss that the surgeon requested that the anesthesia team participate in the provision of postoperative analgesia….” (Emphasis in original.)

Coding expert Kelly Dennis, MBA observes,

Historically, anesthesia practices have relied on documentation by the anesthesia provider to support the surgeon's request for POPM [post-operative pain management], such as a procedure note or anesthesia record indicating the surgeon's request. In the current environment, you should rely on the documentation guidelines as outlined in the NCCI and the recommendations listed by the ASA. Documentation in the medical record must support the surgeon's transfer of care. This requirement means anesthesia practitioners should request written, rather than verbal, communication.

This is quite a difference from the way I often see post op pain services documented. Typically, it is difficult to find a written surgeon's order in the medical record as many of the POPM services are based on verbal orders by the surgeon and documented as requested by the anesthesia provider. Anesthesia practices will need to change their current environment and will be dependent on the surgeons for help!

ASA’s plea that there “be clear education from Noridian to the surgical and anesthesiology communities describing the reasons for the requirements and examples of acceptable pathways to meet the documentation elements” did not receive any response, to our knowledge. Anesthesiologists in Noridian states therefore have the choice of following the most conservative interpretation of the new LCD, or of taking a pragmatic approach based on the ambiguity in the LCD language.  The most conservative interpretation would include the following recommendations:

• Identify clearly the clinician who provided the post-operative pain service.
• Provide a complete description of the block or epidural. Indicate the medication (steroid, neurolytic or anesthetic); specify the method (catheter, ablation or injection); list the site (cervical, thoracic or lumbar); specify temporary versus permanent placement of catheters.
• Indicate the specific condition or diagnosis for which the procedure was performed.  The Noridian LCD contains a list of all the ICD-9 codes that will support the claim.
• Ensure that the pain procedures is documented separately and distinctly from the operative note describing the surgery.
• The anesthesiologist documents the need for and acceptance of transfer of care. 
• If possible, obtain the surgeon’s dictated request and rationale for the transfer of care to anesthesia.

The last item will remain problematic in many facilities—which is why we hope that further guidance will be forthcoming from Noridian, and also that no other carriers adopt the new LCD verbatim.  Medicare is relatively tolerant of templates and it may be possible to include a checkoff box for the surgeon’s request on the medical record.  In the interim, we would encourage any anesthesiologist whose claim for pain management is denied for lack of a written surgeon’s order to appeal the decision.