Proposed “Medical Necessity” Restrictions on Post-Anesthesia Pain Blocks
One of the Medicare Administrative Contractors (MACs), Noridian Administrative Services LLC, has published a proposed policy that would bar payment for peripheral nerve blocks placed pre-operatively for the management of post-operative pain. According to the draft policy, entitled Nerve Blockade: Somatic, Selective Nerve Root, and Epidural,
Reimbursement for the control or management of pain in the immediate postoperative period is bundled 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 reimbursable. Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control.
The last sentence of the quoted paragraph would represent a sharp departure from current coverage rules. Anesthesiologists and other physicians can and do place epidurals and other pain blocks before the start of an anesthesia case in order to control post-operative pain. For several decades at least, the appropriateness of this practice has been well accepted.
There is also, regrettably, a considerable history of insurers bundling the placement of blocks and epidurals for post-operative pain control into the payment for surgical anesthesia services. The American Society of Anesthesiologists’ statement on Reporting Postoperative Pain Procedures in Conjunction With Anesthesia (last amended October 20, 2010) notes that this practice is “contrary to CPT guidance, CCI edits, Medicare contractors’ instructions and the process used to assign base unit values to anesthesia codes” and that it is probably “due to payer confusion regarding the difference between regional anesthesia that is applied as a part of the primary anesthetic as opposed to that which, while placed prior to the onset of anesthesia, is intended primarily to provide postoperative analgesia.” The ASA statement quotes extensively from the sources mentioned and should be consulted by anyone corresponding with a health plan that attempts to include the pain procedure in the payment for the anesthesia service.
The proposed policy published by Noridian focuses on the timing of the pain intervention: “Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control.” The CPT and correct coding references listed in the ASA statement make it very clear, however, that it is the purpose of the block or epidural that governs. If the intervention is “employed primarily for postoperative analgesia” it is separately billable and payable (as long as the anesthesia was not “dependent upon the efficacy of the regional anesthetic technique” and the time spent placing the block before induction or after emergence is excluded from reported anesthetic time). Indeed, the CCI Policy Manual, Version 15.3, Chapter is quoted thus:
[I]f the anesthesiologist performed general anesthesia … and reasonably believes that postoperative pain is likely to be sufficient to warrant an epidural catheter, CPT code 62319-59 may be reported indicating that this is a separate service from the anesthesia service. In this instance, the service is separately payable whether the catheter is placed before, during, or after the surgery.
(Emphasis added.) What, then, should one do about the proposed Noridian policy? First, understand its genesis and its place in the hierarchy of Medicare payment policies, and then join in the effort to prevent the finalization of the problem language.
Where Do New Medicare Payment Policies Come From?
Medicare payment policies come in two basic varieties: National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). The Centers for Medicare and Medicaid Services promulgates NCDs to provide guidance on the conditions for which an item or service is considered to be covered. When there is no applicable NCD that resolves a question of whether a particular item or service is “reasonable and necessary,” MACs including Noridian have the option of adopting LCDs.
The draft LCD must describe the circumstances under which the item or service is reasonable and necessary under the law. Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
Safe and effective; and
Appropriate, including the duration and frequency that is considered appropriate for the item or service, in terms of whether it is;
Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member;
Furnished in a setting appropriate to the patient's medical needs and condition;
Ordered and furnished by qualified personnel;
One that meets, but does not exceed, the patient's medical need; and
At least as beneficial as an existing and available medically appropriate alternative.
As is fully described in Chapter 13 of the Medicare Program Integrity Manual, the LCD process starts with the carrier medical director (CMD) (or with his or her staff), who considers medical literature, the advice of local medical societies and medical consultants, public comments, and comments from the provider community. LCDs that are new or that are revised so as to restrict the definition of medical necessity in an existing LCD require a 45-day comment period followed by a 45-day notice period before the final LCD becomes effective.
The CMD must solicit comments on draft LCDs from other CMDs in the region, from the relevant specialty societies, from the Quality Improvement Organizations, from the general public and last but not least from the Carrier Advisory Committee (CAC).
The CAC is “A formal mechanism for physicians in the State to be informed of and participate in the development of an LCD in an advisory capacity; A mechanism to discuss and improve administrative policies that are within carrier discretion; and A forum for information exchange between carriers and physicians.” In general, there is one CAC per state, although under some circumstances a multi-state carrier may establish a single CAC. Each specialty is entitled to be represented by one physician and an alternate. (Anesthesiology and Interventional Pain Medicine are separate specialties for purposes of CAC representation.)
The carrier must hold a minimum of three meetings per year and may also work with the CAC through telephone and written communications. Noridian has posted the following schedule of CAC meetings that are open to the public and at which the draft nerve blockade LCD will be discussed:
Alaska 05/09/2013
Arizona 05/28/2013
Idaho 05/22/2013
Montana 05/09/2013
North Dakota 05/14/2013
Oregon 04/13/2013
South Dakota 05/16/2013
Utah 05/02/2013
Washington 04/09/2013
Wyoming 05/02/2013
How Can You Affect the LCD Process?
The CAC’s role is advisory only. Decision-making authority rests with the carrier, although the CMD must consult with the CAC on almost every new or revised LCD. The effectiveness of a given CAC, or of individual physicians in the group, obviously depends heavily on the relationships and interactions between CMD and CAC members, as well as on the ability of the representatives of a particular specialty to influence their peers.
Like other representatives in a deliberative body, CAC members are the most effective when they are familiar with the concerns of those whom they represent. Anesthesiologists who will likely be affected by Noridian’s proposed bundling of post-operative pain management into the payment for the surgical anesthesia service should consider contacting their CAC members immediately. The regulations require carriers to make the current member directory available “to the provider community upon request”—but it may be faster to check with your state society or its individual officers to find out the identity of your representative(s). These anesthesiologists are in all likelihood already working on the problem, but you might try to make sure that they have what they need.
The Noridian draft LCD looks like an outlier rather than the vanguard, given the history of payer attempts to bundle post-operative pain procedures with the anesthesia service. In many cases, pain management initiated only after PACU discharge, as proposed, may not provide the necessary relief. The draft policy is questionable on clinical patient care grounds and not just because it would eliminate payment for the interventions in question. We encourage our readers in the nine Noridian states to speak up for their patients, and we hope that this summary explanation of the LCD process and CAC role is helpful to our readers in general.