It is becoming more difficult for anesthesia providers to obtain reimbursement for a chronic pain case. Payer policies have become more stringent and payment more inconsistent. Today’s article dives into the challenges and potential strategies for successful claim submission.
In addition to the anesthesia services many of our clients provide to surgeons and obstetricians, some of our clients are being asked to provide anesthesia for chronic pain providers performing a variety of nerve blocks such as ESI, transforaminal, facet, RFA, spinal cord stims, etc. This particular subset of services poses a number of payment problems and may prove to be considerably less profitable on a per-hour basis than other anesthesia services. Although there are often good and compelling reasons for a practice to provide these services, it is important that providers understand the potential challenges they will inevitably encounter.
Impediments to Payment
The payer fee schedule for codes related to chronic pain nerve blocks is intended to provide sufficient payment for the administration of the procedure and whatever level of analgesia is appropriate. Obviously, there are exceptions where the condition of the patient, the location of the block (e.g., high on the spine) and other patient issues may make it necessary to anesthetize the patient for the procedure. The understanding is that these are the exceptions rather than the rule. As a result, insurance plans may have policies that preclude payment for anesthesia for such procedures. The billing staff must address any denials to determine if there is an opportunity to get the claim paid.
An advanced beneficiary notice (ABN) or similar notification form may work for some patients whose insurance will not cover the anesthesia service. An ABN must be signed prior to the procedure and represent the patients’ acknowledgement that, in the event their insurance does not pay, they will accept personal responsibility for payment. Although the use of ABNs would appear to be a solution to the insurance denial, they are a practical challenge and do not necessarily guarantee payment.
Over the past few years, the coding options for these claims have evolved, making it slightly more difficult to meet the documentation requirements. The following reflects the valid anesthesia (ASA) codes related to chronic pain procedures. The two original codes, 01935 and 01936, were replaced in 2022 by the codes listed below. Clearly, the intent was to specify the “percutaneous” procedure being performed.
01937 – Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic (4 units)
01938 – Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral (4 units)
01939 – Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic (4 units)
01940 – Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral (4 units)
01941 – Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic (5 units)
01942 – Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral (5 units)
The two codes below did remain for those chronic pain procedures that were not done percutaneously and are selected based on patient’s position.
01991 – Anesthesia for diagnostic or therapeutic nerve blocks, other than prone position. (3 units)
01992 – Anesthesia for diagnostic or therapeutic nerve blocks, prone position. (5 units)
A particular source of concern for the coders and a constant source of frustration for providers is the need to specifically document in each case that the procedure was performed with guidance. Many anesthesia providers complain that the blocks are always performed with fluoroscopic guidance. From a compliance perspective, this must be noted on each record.
Across “most” Medicare Administrative Contractors (MACs), there are LCD policies that place limitations on what type of anesthesia can be performed. For example, see below limitation for facets:
General anesthesia is considered not medically reasonable and necessary for facet joint interventions. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely considered medically reasonable and necessary. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review.
For facet intervention, it is saying that general anesthesia is not medically necessary, which means we cannot bill these for general cases. When it comes to MAC cases, it says they will only pay under “rare, unique circumstances” but will not provide a list of diagnoses that support what these rare, unique circumstances are. I have asked this specific question to one MAC—NGS—and was told they will not be providing a listing as the medical necessity would be considered on a case by case basis. In addition, there are some MACs that go so far as to say that even “needle phobia” does not qualify under the “rare, unique circumstances.”
Documentation is Key
The above MAC policy and position is one reason why we often stress during our compliance in-services that anesthesia providers who perform these types of cases need to make sure that they are capturing the comorbid conditions that the surgeon believes makes it medically necessary to have anesthesia for the specific patient, and it cannot just be for patient comfort.
From an auditor’s perspective, they are looking for reasons to recoup any payments that are made inappropriately. If an auditor is reading the clinical documentation and it does not support that guidance was used and that an image was saved, they can take the money back. It is all about proving what you are doing.
A typical review of performance by payer reveals the variety of payer policies and the inconsistency with which claims are adjudicated by insurance plans. Given the constant evolution of payer policies and the economics of this subspecialty, practices are advised to monitor the performance of these services on a periodic basis.
If you have any questions on this topic, feel free to contact your account executive.
With best wishes,