PCA:  CASH COW OR COURTESY CALL?
By Bellinger Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

One recurrent question that I receive on a regular basis:  “Is it worth it to provide and bill for IV PCA services?  The answer to this question for 99% of the anesthesia groups that perform this service is a resounding NO!!!  The below survey of payer billing rules and regulations overwhelmingly support this response:

MEDICARE & MEDICAID

Medicare does not allow PCA as a procedure.  PCA is generally considered a component of an E&M service for pain management.  As per the Federal Register, it is included in the surgeon’s global unless a special situation exists such as:  (1) A patient has addiction issues and the surgeon transfers pain care to a specialist trained in addiction medicine/Opiod management; (2) Pain is so severe a specialist is called. 

BCBS OF FLORIDA & MOST OTHER STATE BCBS PAYERS
For BCBS of Florida, PCA is considered not separately payable regardless of whether the surgeon or anesthesiologist provided the service.  Physician management of PCA is included in the surgeon’s global payment and will not be paid to the anesthesiologist when billed.  However, when the provider initiates the PCA in the PACU, as part of anesthesia time, set up time can be added to the anesthesia time units. PCA services after anesthesia time ended, including initial setup, subsequent adjustments, or follow up is routine post op pain management and is not separately billable/payable.

AETNA

For Aetna, when PCA is initiated, Aetna will pay for the initial catheter insertion, if not performed as part of a surgical anesthesia.  Time units and anesthesia base units are not applicable in this instance.  Aetna will provide payment for postoperative PCA evaluation and management services when billed with an appropriate E&M code (99231 – 99233), with appropriate documentation.  Therefore, Aetna will not pay for any PCA (initiation or management) in relation to anesthesia services – meaning they will only pay for such PCA services as PCA for Chemotherapy (unrelated to anesthesia/surgery).

UNITED HEALTHCARE

For United Healthcare, any subsequent IV PCA management services should not be reported separately.  The hospital nursing staff is responsible for the ongoing IV PCA monitoring that is considered included in the surgeon’s global fee, and any subsequent IV PCA management by a physician is considered to be included in the postoperative evaluation and management visits.  However, if IV PCA is initiated for pain control (unrelated to anesthesia/surgery), e.g. chemotherapy pain control, the physician may bill  for the insertion of an intravenous catheter for PCA (CPT codes 36000 and 36410) and be reimbursed.

GENERAL RULES

For most payers, IV PCA is NOW generally considered bundled into the basic anesthesia/surgical service and is not separately billable/payable – both IV PCA initiation as well as rounding and ongoing monitoring are considered integral services of the hospital nursing staff and are included in the surgeon’s global fee.  Additionally, the 2010 CPT guidelines for the CPT code utilized for IV PCA initiation (CPT code 96374 – Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance) state that:

“These services typically require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff.  Typically such infusions require special consideration to prepare, dose or dispose of, require practice training and competency for staff who administer the infusions, and require periodic patient assessment with vital sign monitoring during the infusion.  These codes are not intended to be reported by the physician in the facility setting.”

In conclusion, the days of billing for PCA (related to surgery/anesthesia) are at an end.  For the overwhelming majority of payers, these are no longer billable/payable services (other than for such non-surgical/anesthesia services as chemotherapy).    Therefore, IV PCA initiation and rounding – for the most part – are being provided as a courtesy to the hospital/surgeons because there are less than a handful of payers that will reimburse for this service — and those that still do just are not abreast of current billing & reimbursement rules & regulations.  IV PCA services may only be billed to the very select, few payers that have very “unique” policies or contractual language/provisions that specifically spell out coding, billing and reimbursement  methodology.   I recommend that you contact your Medac Practice Management Representative and have him/her perform a reimbursement analysis to:   (1) determine if you are receiving enough reimbursement to at least cover the cost of providing the service; (2) determine whether you are going to continue providing these services;  or (3) turn it back over to the surgeons.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.