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Summer 2014

Changes Involving Payment for Post-Operative Pain Procedures

Neda M. Ryan, Esq.
Clark Hill, PLC, Birmingham, MI

For as long as anesthesia providers can remember, the payment for post-operative pain procedures has been bundled into the surgeon’s global fee. The exception to this general rule arises when the surgeon requests the anesthesiologist to administer the service. Although the National Correct Coding Initiative (NCCI) Coding Policy Manual for Medicare Services (Manual) provision has not changed, Medicare contractors’ payment for post-operative pain procedures is beginning to shift and the anesthesia community must be aware of this shift and ensure compliance with The Center for Medicare and Medicaid Services’ (CMS’) and its contractors’ documentation requirements.

The CMS annually releases the NCCI Manual, which was developed to “promote national correct coding methodologies … to control improper coding leading to inappropriate payment in Part B claims.” The Manual includes a section specifically pertaining to billing for anesthesia providers furnishing post-operative pain procedures. This section provides that post-operative pain services are included in the surgeon’s global fee for the surgical procedure and payment to an anesthesia provider is appropriate when medically necessary and when the surgeon documents in the record that the service was referred to an anesthesia provider and the reason for the referral. Specifically, the Manual states as follows:

Postoperative pain management services are generally provided by the surgeon who is reimbursed under a global payment policy related to the procedure and shall not be reported by the anesthesia practitioner unless separate, medically necessary services are required that cannot be rendered by the surgeon. The surgeon is responsible to document in the medical record the reason care is being referred to the anesthesia practitioner.

(Emphasis added.) Although the requirement that the surgeon document the medical necessity for referring the service to the anesthesia provider has long existed, in practice, CMS contractors have not typically referred to the surgeon’s records to determine whether this requirement has been satisfied. However, this practice is quickly changing, especially in two Part B jurisdictions.

Effective for services performed on or after June 9, 2014, Noridian Healthcare Solutions, LLC (Noridian), the Part B Medicare Administrative Contractor (MAC) for Jurisdiction F, covering Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming, post-operative pain management services are separately reimbursable to the anesthesia provider under Part B 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 (See local coverage determination (LCD) 33188, Nerve Blockade: Somatic Selective Nerve Root Block, and Epidural). Noridian’s recent change has brought the LCD’s documentation requirements in line with those set forth in the Manual. In other words, for anesthesia providers to receive payment for post-operative pain management services, both the surgeon and the anesthesia provider must also document the medical necessity for the transfer. Simply stating that a surgeon requested the transfer of care to the anesthesia provider will likely be insufficient for payment.

Although Noridian is the only MAC officially revising its LCD at this time, some anesthesia providers in Wisconsin Physician Services (WPS) Jurisdiction 8, covering Michigan and Indiana, have experienced claim denials and requests for additional documentation when they have submitted claims for post-operative pain management services. Importantly, WPS has been requesting the surgeon’s documentation to confirm medical necessity. More importantly, WPS recently stated in a teleconference that it intends to deny all claims involving postoperative pain blocks and, in doing so, will request that the surgeon’s documentation be submitted with the appeal.

In light of these recent shifts in official, and unofficial, local policies, it is of utmost importance that anesthesia providers ensure that their documentation properly reflect the request by a surgeon to administer postoperative pain management services as well as the medical necessity for the request. It is also imperative that anesthesia providers communicate with the surgeons the need for the surgeon’s record to include documentation of the medical necessity of the request. Failure of both parties to include adequate documentation in the record will result in claim denials and/or a request for overpayments on the part of the carriers enforcing the more stringent policies.

Although the national guidelines in the Manual have enunciated the surgeon’s obligation, in practice, anesthesia providers have received payment for services without the MAC reviewing the surgeon’s documentation. As we can see, two jurisdictions have begun to take a rather aggressive approach in implementing the long-standing national guidelines. Although the new local policy shifts appear to affect only Noridian’s and WPS’s jurisdictions thus far, as CMS continues to strengthen its grip on payment for services, all anesthesia providers should expect this requirement to affect their jurisdictions in the near future. As such, the sooner anesthesia providers in other jurisdictions ensure both they and surgeons comply with the national requirement, the easier the transition will be when it takes place in their respective jurisdictions and the less anesthesia providers will be faced with claim denials and/or requests for overpayments.

Neda M. Ryan, Esq. is an associate with Clark Hill, PLC in the firm’s Birmingham, MI office. Ms. Ryan practices in all areas of health care law, assisting clients with transactional and corporate matters; representing providers and suppliers in health care litigation matters; providing counsel regarding compliance and reimbursement matters; and representing providers and suppliers in third party payer audit appeals. She can be reached at (248) 988- 5884 or at