Highmark Commercial Medical Policy in West Virginia

Section: Anesthesia
Number: A-10
Topic: Pain Control
Effective Date: July 21, 2008
Issued Date: January 17, 2011
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

Patient Controlled Analgesia (PCA)

When patient controlled analgesia (PCA) is initiated in the recovery room by an anesthesiologist as part of his anesthesia time (see Medical Policy Bulletin A-8), the initial set-up time for PCA may be incorporated into the total number of anesthesia time units reported.

Any PCA services performed after the anesthesia care has ended, including initial set-up, subsequent adjustments, or follow-up related to this therapy are considered routine postoperative pain management, regardless of who performs it. When performed by the doctor who administered anesthesia, or by a member of his group/association, the postoperative pain management is part of the global anesthesia allowance. As such, if billed separately, the pain management is not covered. A participating, preferred, or network provider cannot bill the member for the denied service. However, when postoperative pain management is provided by a doctor other than those specified above, it should be denied as not covered. A participating, preferred, or network provider can bill the member for the denied service.

PCA administered for nonsurgical pain management is considered an integral part of a doctor's medical care. It is not eligible as a separate and distinct service when performed with medical care. If nonsurgical PCA is reported on the same day as medical care, and the charges are itemized, combine the charges and pay only the medical care. Payment for the medical care performed on the same date of service includes the allowance for the nonsurgical PCA. A participating, preferred, or network provider cannot bill the member separately for the nonsurgical PCA in this case.

If the nonsurgical PCA is performed independently, process it under code 99499.

Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the nonsurgical PCA. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

Epidural Analgesia

The pre-, intra, or post-operative insertion of an epidural catheter for post-operative pain control (codes 62318 and 62319, as appropriate) is not considered part of the global anesthesia allowance, and therefore, is eligible for separate payment. Daily Management of epidural drug administration (code 01996) is also eligible for separate payment after the day on which the catheter is inserted. Daily Management reported on the same day as the catheter insertion is not covered. A participating, preferred, or network provider cannot bill the member for Daily Management on the same day as the catheter insertion. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Payment can also be made for the insertion of an epidural catheter (codes 62318 and 62319, as appropriate) for the treatment of a nonsurgical condition. Daily Management of epidural drug administration (code 01996) is also eligible for separate payment after the day on which the catheter is inserted. Daily Management reported on the same day as the catheter insertion is not covered. A participating, preferred, or network provider cannot bill the member for Daily Management on the same day as the catheter insertion. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

In addition, an epidural injection administered as a therapeutic agent in the treatment of a nonsurgical condition (e.g., chronic low back pain, cancer, etc.) should be reported under code 62311 or 62319, as appropriate. Any follow-up care should be reimbursed based on the level of medical care reported (e.g., intermediate, extended, etc.).

NOTE:
Refer to Medical Policy Bulletin A-5 for epidural anesthesia for relief of pain during labor and delivery.

Nerve Blocks

An injection/block administered pre-, intra-, or postoperatively is not considered part of the global anesthesia allowance and, therefore, is eligible for separate payment. These injection/block procedures should be reported under codes 62273-62282, 62310-62319, 64400-64450, 64505-64530, as appropriate.

Injections/blocks administered as a therapeutic agent in the treatment of a nonsurgical condition should be reported under codes 62273-62282, 62310-62319, 64400-64450, 64505-64530.

Refer to Medical Policy Bulletin S-100 when multiple nerve blocks are given during the same session.

Refer to Medical Policy Bulletin A-8 when a nerve block is administered as an anesthesia service.

Refer to Medical Policy Bulletin S-40 for drug infusion via an implantable pump.

Refer to Medical Policy Bulletin A-2 for additional information on nerve blocks and modifier 59. The A-2 policy guidelines are also applicable to nerve blocks when provided as anesthesia for surgery by the operating surgeon.

Refer to Medical Policy Bulletin S-189 for information on transforaminal epidural injections.

Refer to Medical Policy Bulletin Z-61 for information on paravertebral facet joint nerve blocks.

Description

Various methods of pain management may be used for both post-operative and nonsurgical pain control. Below are the most common techniques:

Patient Controlled Analgesia

Patient controlled analgesia therapy is a technique for pain management that involves self-administration of intravenous drugs through an infusion device.

Epidural Analgesia

Epidural analgesia involves the administration of a narcotic drug through an epidural catheter.

Nerve Blocks

A nerve block involves the injection of an anesthetic agent into or around a given nerve.

Procedure Codes

622736228062281622826231062311
623186231964400644026440564408
644106441264413644156441764418
644206442164425644306443564445
644476445064505645086451064517
645206453099499   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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[Version 008 of A-10]
[Version 007 of A-10]
[Version 006 of A-10]
[Version 005 of A-10]
[Version 004 of A-10]
[Version 003 of A-10]
[Version 002 of A-10]
[Version 001 of A-10]

Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Highmark West Virginia plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Highmark West Virginia retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark West Virginia. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.