Medicare Contractor Proposes Limiting Coverage of Post-Op Blocks to Post-PACU Placement

    Medicare Contractor Proposes Limiting Coverage of Post-Op Blocks to Post-PACU Placement
    By Christine Locay, JD, RHIA, CPC

    4/9/2013

    Noridian Administrative Services (NAS) administers Medicare Part B for Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming.  NAS has released a draft local coverage determination (LCD) (see attached policy) governing coverage of pain blocks for all 10 states listed above.  Of particular significance, NAS is proposing to limit coverage (and thus reimbursement) of postoperative pain blocks to blocks that are placed after PACU discharge.

     

    The LCD states

     

    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.

    PROPOSED/DRAFT Local Coverage Determination (LCD): Nerve Blockade: Somatic, Selective Nerve Root, and Epidural (DL33188)(emphasis provided).

    The proposed LCD can be challenged on several grounds such as clinical practice standards and the American Medical Association’s CPT coding guidance, which are discussed below; however, the ultimate flaw with the policy is that the limitation of coverage for postoperative pain blocks directly contradicts national CMS policy.

    I.    The LCD contradicts national CMS policy that is set forth in CMS’ National Correct Coding Initiative Policy Manual (NCCIPM).
    As a Medicare Administrative Contractor (MAC), NAS must comply with CMS’ rules governing the development of LCDs.  In particular, the Medicare Program Integrity Manual prohibits an LCD from contradicting national CMS coverage policies:
    The LCD shall be clear, concise, properly formatted and not restrict or conflict with NCDs or coverage provisions in interpretive manuals. If an NCD or coverage provision in an interpretive manual states that a given item is “covered for diagnoses/conditions A, B and C,” contractors should not use that as a basis to develop LCD to cover only “diagnoses/conditions A, B and C.” When an NCD or coverage provision in an interpretive manual does not exclude coverage for other diagnoses/conditions, contractors shall allow for individual consideration unless the LCD supports automatic denial for some or all of those other diagnoses/conditions.

    Chapter 13 – Local Coverage Determinations, 13.5 – Content of an LCD, January 15, 2013.

    Which policy does the LCD contradict?  CMS’ National Correct Coding Initiative Policy Manual (NCCIPM) was revised in 2013 and clearly states that postoperative blocks are covered whether they are placed preoperatively, intraoperatively, or postoperatively (assuming medical necessity).  Specifically, the NCCIPM states

    An epidural or peripheral nerve block injection . . . for postoperative pain management in patients receiving general anesthesia, spinal (subarachnoid injection) anesthesia, or regional anesthesia by epidural injection as described above may be administered preoperatively, intraoperatively, or postoperatively.

    NCCIPM, Anesthesia, Revision Date (Medicare): 1/1/2013 (emphasis provided).

    As to whether the NCCIPM is considered national CMS policy, the NCCIPM itself states that “[s]ince the NCCI is a CMS program, its policies and edits represent CMS national policy. However, NCCI policies and edits do not supersede any other CMS national coding, coverage, or payment policies.” NCCIPM Introduction – 5 (emphasis provided).
    In 2012, the Medicare Appeals Council addressed the issue of whether LCDs supersede national CMS policy, specifically the NCCIPM, and concluded that LCDs do not supersede the NCCIPM:

    Contrary to the appellant’s contentions, the CPT code descriptors in the LCD do not supersede NCCI correct coding policies . . . . The NCCPM [The National Correct Coding Policy Manual] also provides that “[s]ince the NCCI is a CMS program, its policies and edits represent CMS national policy. However, NCCI policies and edits do not supersede any other CMS national coding, coverage, or payment policies.”

    DECISION OF MEDICARE APPEALS COUNCIL Docket Number: M-10-1708, Med Health Services v.  Highmark Medicare Services, Claim for Supplementary Medical Insurance Benefits (Part B), June 14, 2012.

    In summary, the NCCIPM is clearly CMS national policy, and CMS national policy is to cover and reimburse postoperative pain blocks whether they are placed preoperatively, intraoperatively, or postoperatively.  As such, NSA’s proposed LCD directly and inappropriately contradicts national policy, and therefore, should not be finalized.

    II.    The LCD contradicts the American Medical Association’s (AMA’s) coding instructions for postoperative pain blocks.

    While MACs are not bound by the AMA’s coding instructions, the AMA’s instructions represent generally-accepted industry standards for billing and coding.  The AMA has consistently stated over many years that postoperative blocks are separately reportable whether they are placed preoperatively, intraoperatively, or postoperatively.

    Most recently, the AMA addressed this issue in December of 2012 in its Special Edition Q&A of the CPT Assistant:

    Anesthesia Question: When an anesthesiologist performs a postoperative pain management injection prior to surgery in the “pre-op holding area” or postsurgical “recovery room,” may the injection procedure be reported or must all services be performed in the operating/procedure room?

    Answer: When the injection is performed separately from the anesthesia for the surgery, it would be reported separately as an independent procedure. When general anesthesia is administered and epidural or nerve block injection(s) are performed to provide postoperative analgesia, they are separate and distinct services and are reported in addition to the anesthesia code. This is true irrespective of the timing (pre-, intra-, or post-operative) of the placement of the block (insertion of catheter, injection of narcotic, or local anesthetic agent). However, when the block procedure is used primarily for the anesthesia itself, the service should be reported using the anesthesia code alone. In a combined epidural and general anesthetic, the block cannot be reported separately. The criteria as to whether a block is separately reportable from an anesthesia service do not include a requirement that the block be performed in the operating/procedure room.

    Thus, the LCD’s provision limiting reimbursement to postoperative blocks placed after PACU discharge is contrary to the AMA’s official coding guidelines and interpretation which states that when the block is placed is irrelevant.

    III.    The LCD contradicts the American Society of Anesthesiologists’ (ASA’s) position statement on postoperative pain blocks and the common clinical practice of placing postoperative pain blocks prior to induction.

    The ASA’s statement on Reporting Postoperative Pain Procedures in Conjunction with Anesthesia  (attached) reinforces that postoperative blocks may be placed preoperatively, intraoperatively, or postoperatively so long as certain criteria are met:

    A provider may bill for a regional anesthetic technique as a service separate from the anesthetic if the regional technique is employed primarily for postoperative analgesia and if the following conditions apply:

    1.1    The anesthesia for the surgical procedure was not dependent upon the efficacy of the regional anesthetic technique –
    1.2    The time spent on pre- or postoperative placement of the block is separated and not included in reported anesthetic time –
    1.3    Time for a post surgical pain block that occurs after induction and prior to emergence does not need to be deducted from reported anesthesia time –

    REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH ANESTHESIA, Committee of Origin: Economics (Approved by the ASA House of Delegates on October 17, 2007 and last amended on October 20, 2010).

    Specifically, section 1.2 also states that “[p]ost surgical pain blocks are most frequently placed before anesthesia induction or after anesthesia emergence.”

    Therefore, the LCD contradicts generally-accepted coding and billing standards and inappropriately limits coverage to blocks placed after PACU discharge despite the common clinical practice of placing postoperative blocks before induction or after emergence.

    Anesthesia providers should take action.

    Medac encourages all providers in Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming to communicate this information to the following NAS contacts via written correspondence or email.  We also recommend contacting the Contractor Medical Directors by phone.

    It is extremely important to stop implementation of this policy as other MACs may implement similar policies if NAS is successful.  Feel free to copy this article in your correspondence but be sure to include source citations as well.
    Gary Oakes, MD
    Contractor Medical Director
    Noridian Administrative Services, LLC
    P.O. Box 6740
    Fargo, ND 58108-6740
    Phone: 701-205-5359
    E-mail: Gary.Oakes@noridian.com

    Bernice Hecker, MD, MHA, FACC
    Contractor Medical Director
    Noridian Administrative Services, LLC
    P.O. Box 6740
    Fargo, ND 58108-6740
    Phone: 206-328-4093
    E-mail: bernice.hecker@noridian.com

    Providers may send written comments for Part B regarding draft policies to:

    Contractor Medical Directors
    Policy Development
    Medicare Part B
    Noridian Administrative Services, LLC
    900 42nd Street S
    P.O. Box 6740
    Fargo, ND 58108-6740

    OR

    E-mail: policyb.drafts@noridian.com

    In addition, providers may communicate their concerns at Carrier Advisory Committee (CAC) meetings; however, all of the CAC meetings are closed except for the CAC meetings in Washington (April 9, 2013 and August 13, 2013) and Alaska (May 9, 2013 and September 19, 2013).  The following link provides information on the CAC meetings:

    https://www.noridianmedicare.com/partb/contact/cmdcac/cac_meetings.html

    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.  This alert does not constitute legal advice.