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Fading Away: Anesthesia for Chronic Pain

April 1, 2024

It was one of those end-of-an-era moments. Standing in the well of the House, before a joint session of Congress, was the “American Caesar,” General Douglas McArthur, bidding farewell to the nation after 52 years of service. First in his class at West Point, winner of the Congressional Medal of Honor and Military Governor of Japan, he was now retiring. In his final remarks before an adoring Congress, the 5-star general famously said: “Old soldiers never die; they just fade away.”

There is, from time to time, a phasing out of things we’ve grown accustomed to. Gradually, we can see it slipping away. That is now the situation when it comes to anesthesia for chronic pain. It is, for the most part, on its way out—at least in terms of Medicare. It is fading away.

A few years ago, we published two articles reflecting Medicare’s reticence to reimburse anesthesia services in cases where a chronic pain physician is performing an injection for his or her patient. This alert will act to update our readers on the current status of such claims.

Anesthesia for Facets

You may recall that Medicare published policy language back in 2021 that stood to make it nearly impossible for anesthesiologists and CRNAs to get paid in cases involving anesthesia for facet joint “interventions,” which include four types of procedures: Intraarticular facet joint injection (FJI), medial branch block (MBB), radiofrequency ablations (RFA) and facet cyst rupture/aspiration (FCRA). One Medicare local coverage determination (LCD), i.e., medical policy, contained the following language:

General anesthesia is considered not 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 reimbursable. 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.

So, if you are listing general as the anesthesia technique for these cases, we will not submit the claim to Medicare due to the above LCD language. In addition, the above language would seem to imply that utilizing MAC as the technique would lead to denial on the first pass. However, we have learned from Medicare auditors that providers’ use of the QS modifier in these cases (indicating MAC as the technique) does not always lead to an initial denial. However, upon audit, the payer will most likely request a recoupment.

Anesthesia for Epidurals

We have also apprised our readers that reimbursement for anesthesia in connection with epidural steroid injections (ESIs) is in jeopardy, as well. In 2021, a representative Medicare LCD entitled “Epidural Steroid Injections for Pain Management” (which includes interlaminar, transforaminal and caudal approaches) was published and contained the following language:

Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient.

While Medicare has thus far refused to clarify which “exceptional and unique cases” would establish a medical necessity for the services of an anesthesia provider in an ESI case, the overall takeaway is that these services will rarely be reimbursed to anesthesiologists and anesthetists.

Tightening the Screws

In a recent post-payment audit performed by one of the Medicare contractors, all of the group’s reviewed claims involving anesthesia for facets and ESIs were deemed not medically necessary. The contractor in question was Novitas, which has jurisdiction over the following states for Medicare Part B claims: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, District of Columbia, Delaware, Maryland, New Jersey and Pennsylvania. This also happens to be the only Medicare contractor that currently has a monitored anesthesia care (MAC) policy.

The Novitas MAC policy states that unless one or more of the approved diagnosis codes listed in the policy are found on the claim form, the claim will be denied. The claims in the above-referenced audit contained the required diagnoses. The problem is that there was a lack of sufficient support for those diagnoses in the medical record. The MAC policy goes on to state:

The medical condition must be significant enough to impact on the need to provide MAC such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily sufficient.

Accordingly, your documentation in such cases will need to strongly support why the patient needs the anesthesia service. You must document in plain language the reasons why your service is medically necessary.

We want to further stress that a group that routinely submits anesthesia claims in connection with these chronic pain procedures will invite an audit. This was the case with the group in the above example. Again, from one of the above LCDs we read, “Frequent reporting of these services together may trigger focused medical review.” Medicare auditors have made it clear that they expect submission of such cases to be rare.

To sum up, anesthesia providers should simply avoid or reduce the provision of services in such cases—at least in the context of Medicare beneficiaries. Where you believe such cases have medical necessity, you should fortify your diagnostic and pre-anesthesia assessment documentation. A patient status of P3 or higher would be a helpful start, but you will want to provide documentary support for that assignment. Again, list any co-morbidities or other patient circumstances that may strengthen your argument that anesthesia was medically necessary and that fully justify the diagnosis code(s) assigned.

The recent Novitas audit is just the latest example of how judicious anesthesia providers need to be when it comes to the provision and documentation of anesthesia in chronic pain cases.

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