MDs can be confused about pain care payment
Teach docs how to get paid
With the growing concern over the quality of pain management, physicians are trying to catch up on the latest in palliative care, but many are still confused about how to get reimbursed for their pain management services.
Hospices can help promote better pain management and cultivate referrals not only by helping physicians become better educated about pain management but also by providing practical advice about getting reimbursed.
Pain management has garnered increased attention recently. End-of-life care advocates have long criticized physicians for not providing proper palliative care to their patients. This sentiment has been underscored by recent lawsuits for inadequate pain management, including a case involving an 85-year-old cancer patient.
Just as many physicians lack understanding about palliative care, many are equally befuddled about getting reimbursed for pain management treatments, such as the use of opioid drugs or drugs with an off-label pain management benefit.
Basic pain management drugs come in two forms: nonsteroidal anti-inflammatory drugs, such as ibuprofen and aspirin, and opioids, such as morphine, fentanyl, or codeine.
In most cases, pain drugs are given orally. Other than the cost of the drugs themselves, drugs that are self-administered are not covered by Medicare, but drugs that are administered in the physician’s office via injection or infusion pump have a variety of reimbursement codes associated with them, says Laurie Lamar, RHIA, CCS, CTR, CSS-P, reimbursement specialist with the American Society of Clinical Oncology in Alexandria, VA. The remainder are administered intramuscularly, subcutaneously, intravenously, intraspinally, or intraventricularly.
For IV and intraspinal administration, an infusion pump is used (E0779-E0791, infusion supplies). An implantable infusion pump (E0782- E0785) is covered when it is used to administer opioid drugs (e.g., morphine) intrathecally or epidurally (64999) for treatment of severe chronic intractable pain of malignant or nonmalignant origin in patients who have a life expectancy of at least 3 months and who have proven unresponsive to less invasive medical therapy as determined by the following criteria:
• The patient’s history must indicate that he/she would not respond adequately to non-invasive methods or pain control, such as systemic opioids (including attempts to eliminate physical and behavioral abnormalities which may cause an exaggerated reaction to pain).
• A preliminary trial of intraspinal opioid drug administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate adequately acceptable pain relief and degree of side effects (including effects on the activities of daily living) and patient acceptance.
Reimbursement for patient use of an infusion pump is dependent upon whether the physician’s office owns the pump. If it does, the practice can bill its durable medical equipment regional carrier using its provider number. If it rents the pump from a vendor, the vendor is responsible for billing Medicare.
Outside of billing for pump rental, oncologists have other reimbursement opportunities. The insertion of a catheter and implantation of a pump used for pain management is covered by Medicare. Catheter and pump implantation codes include:
• 62350 — implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term pain management via an external pump or implantable/infusion pump without laminectomy;
• 62351 — with laminectomy;
• 62355 - removal of previously implanted intrathecal; or epidural catheter;
• 62360 - implantation or replacement of device intrathecal or epidural drug infusion, subcutaneous reservoir;
• 62361 - non-programmable pump;
• 62362 - programmable pump, including preparation of pump, with or without programming.
Physicians can also use codes 96520, refilling and maintenance of portable pump, and 96530, refilling and maintenance of implantable pump or reservoir, but they should not be used to report port flushing.
In the rare instance that a physician administers pain management drugs in the office or if drugs are administered in a hospital or outpatient facility, the physician can also bill for related procedures, such as injections.
CPT changes clarify pain management
"There has been much confusion when reporting pain management procedures. So much so that the American Medical Association [AMA] made massive changes to CPT 2000 in hopes of clarifying the coding of injection, drainage, and aspiration procedures performed in pain management," says Laurie Castillo, MA, CPC, CPC-H, president of the American Association of Procedural Coders’ Northern Virginia Chapter and consultant with Physician Coding & Compliance Consulting, both in Manassas, VA. (See chart detailing these changes below)
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Choosing the appropriate drug is also a challenge for many physicians. Medicare regulations mention common drugs that can be used with infusion pumps for intractable pain, such as morphine. But the array of pain management drugs is much wider than that, says Terry Gutgsell, MD, medical director of the Hospice of the Bluegrass in Lexington, KY. Gutgsell often advises physicians in palliative care.
Drugs that have primary uses outside palliative care include methadone (used to treat heroine addiction), J1230; ketamine (anesthesia); and pamidrinate (bone resorption in metastatic breast cancer), J2430. While these drugs are effective, physicians have the burden of proving medical necessity, he says. This is especially important for expensive drugs like pamidrinate, which can cost $600 to $1,200 for a single injection. Gutgsell says physicians need to prove necessity by providing data published in journals. When physicians seek advice from pain management experts, Gutgsell says physicians should ask for published data to support the recommendation.
In addition, Lamar recommends following Medicare regulations for off-label use of drugs and biologicals. Off-label use of drugs is covered when all of the following criteria are met:
• The drug meets the definition of drugs and biologicals.
• The drug is the type that cannot be self-administered.
• The drug meets all the general requirements for coverage of items as incident to a physician’s services.
• The drug is reasonable and necessary for the diagnosis or treatment of the illness or injury for which it is administered according to accepted standards of medical practice.
• The drug is not excluded as a drug used for immunization.
• The drug has not been determined by the FDA to be less than effective.
Unfortunately, cancer often results in a terminal diagnosis. For many cancer patients, hospice is an appropriate setting for their care, including pain management. But the treating physician maintains oversight of the patient, working with hospice professionals and medical directors. The physician who manages patient pain in the hospice setting can bill for care plan oversight services (99377-93778) each month.
For example, if a physician adjusts pain medication for his or her patient and communicates the changes to hospice staff, the physician can bill 99377 if the oversight service lasts less than 30 minutes or 99378 if the service is more than 30 minutes.
The oversight service does not have to be continuous, Lamar says. The billed time can be accumulated over a one-month period and does not have to be face-face time as long as the physician has had at least one face-to-face contact within six months of the time the service is billed.
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