A Higher Hurdle: Anesthesia for Facets Faces Uphill Battle

Summary

It's not getting any easier for anesthesiologists and anesthetists who provide services in pain clinics. Medicare recently released a new policy that will make it more difficult to get paid in facet intervention cases.

From the crease of the valley below, you can see the degree of the slope just ahead. The walk thus far has been at either a level grade or a downward tilt. Now, greater energy must be expended as the road begins angling upward, with an even more exaggerated incline toward the top. The task looks so daunting, you begin to wonder if it's worth the effort.

Hikers and mountain climbers know and understand that the real challenge comes with moving uphill. That's when lung capacity and heart activity are truly tested, and that's when one can feel the pain and strain of the struggle. It is becoming an uphill struggle for anesthesia practitioners in the context of chronic pain. Years ago, they could see the beginnings of a reticence to reimburse anesthesia covering a pain physician's spinal or peripheral injections. Often, these services would be performed with monitored anesthesia care (MAC); but sometimes propofol would be used, and the MAC would be transformed into a general anesthetic. Some payers began putting up roadblocks to payment in the MAC cases, and some began denying such services even where a general was used. The pattern of payer pushback in the last few years has been like a gentle, upward-sloping ridge—getting a little more difficult to get paid as time goes on—but, in recent weeks, it's become more like the sharp-angled peak of the Matterhorn.

New Obstacle

When it comes to one particular chronic pain treatment, Medicare has published new policy language that will make it nearly impossible to get reimbursement from the government payer. The pain treatment involves facet joint "interventions," which include four types of procedures: Intraarticular facet joint injection (FJI), medial branch block (MBB), radiofrequency ablations (RFA) and facet cyst rupture/aspiration (FCRA). According to one Medicare local coverage determination (LCD), published earlier this year, facet joint interventions are considered medically necessary for the diagnosis and treatment of chronic pain in patients who meet ALL the following criteria:

· Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale

· Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated)

· Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)

· There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity

All these conditions would have to be present in order for the chronic pain practitioner to receive payment. For the anesthesia provider to be paid, not only would these conditions have to be present, but an even higher standard would have to be met. The above-referenced LCD goes on to state the following:

General anesthesia is considered not reasonable and necessary for facet joint interventions. Neither conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review.

So, while facet interventions are payable under limited circumstances to the pain clinic, reimbursement to the anesthesia provider brought in to provide a MAC or general anesthetic service will be denied on the first pass. You would need to go through an appeals process, and the Medicare contractor would then, on a case-by-case basis, decide whether or not there was sufficient medical necessity present to justify payment. It would appear that such payment would be rare. So where does that leave us?

Suggested Solutions

As noted above, it has been getting increasingly difficult for anesthesiologists and anesthetists to obtain payment for covering pain injections, generally. This new policy, however, represents a new level of difficulty, with Medicare putting a full-court press on anesthesia in connection with facet procedures. One solution would simply be to avoid, if possible, providing such services, as payment has become questionable—at least in the context of Medicare beneficiaries. However, this option may not be optimal as this may cause an unwanted rift between the anesthesia group and the pain physicians. If a doctor requests your presence and assistance due to a desire to make their patient's experience as comfortable and pain-free as possible, it will be difficult to tell him or her that you can no longer provide such services. There is, of course, another solution.

Due to the wording of the above-referenced LCD, which is replicated in all the related Medicare contractor polices we could find, it would be reasonable to conclude that providing such a service would meet the threshold needed for issuing to the patient an Advanced Beneficiary Notice (ABN). Medicare allows these forms to be presented to a patient prior to the service where the clinician believes that Medicare is likely to deny the service. That would seem to be the case here. The ABN would need to outline the likelihood of denial, as well as the estimated cost of the anesthesia service. The patient would then need to sign the form, signifying their understanding that, if the service is ultimately denied by Medicare, it would be the patient's responsibility to pay the anesthesia bill in full.

Either of these solutions will allow you to mitigate your risk in performing a service that will be rarely paid. However, there are still some circumstances where Medicare may provide reimbursement in connection with these facet cases. The problem is we don't know what those precise circumstances are. Our representatives recently attended a meeting with one of the Medicare contractors who was addressing this new policy. We put this question to the contractor: What are the rare and unique circumstances that would allow these anesthesia services to get paid? The contractor responded that they would not provide any examples of such circumstances. Instead, they insisted, it would be up to individual consideration.

That said, in order to increase the likelihood of Medicare reimbursement for these cases, we recommend that, in addition to submitting the ABN, you fortify your diagnostic and pre-anesthesia assessment documentation. A patient status of P3 or higher may help, but you will want to provided documentary support for that assignment. List any co-morbidities or other patient circumstances that may undergird the argument that anesthesia was medically necessary.

While anesthesia faces an increasingly difficult uphill climb when it comes to getting paid for anesthesia in the chronic pain context, all hope is not lost. There are strategies still available to obtain some measure of payment or, at the very least, avoid losing ground.

If you need instruction on the use of the ABN form, please contact your account executive or contact us at info@anesthesiallc.com.