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Pain management payment policies can be vague, sometime leading to denials, despite a physician’s best efforts to follow a Medicare carrier’s medical review policy.
If, however, physicians follow the Agency for Health Care Quality and Research (AHCQR) cancer pain guidelines, they can make their pain management claims virtually bulletproof. These standards not only mirror Medicare policy, but also provide a more detailed process for determining medical necessity.
"If you follow [AHCQR] guidelines and document each step, I think the guidelines will lend credence to appropriate coding," says Terence Gutgsell, MD, medical director for the Hospice of the Bluegrass in Lexington, KY. Gutgsell often provides palliative care advice to his hospice’s referring physicians.
There are a number of pain management options available to treat cancer pain, ranging from nonsteroidal anti-inflammatory drugs (NSAIDs) to opioids. In addition, there are a variety of delivery options, including oral drugs, injections, and infusions.
With so much to choose from, how can practices be assured the drugs and procedures they choose will be reimbursed? For Medicare, local medical review policies (LMRPs) determine whether any given pain management regimen will be reimbursed. In most cases, LMRPs include themes similar to AHCQR guidelines. But LMRPs can be vague at times, opening the possibility for payment denial.
For example, code 62318 (injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance(s) [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or 62319 (lumbar, sacral [caudal]) are used to report epidural injections. While these injections and nerve blocks are considered to be medically necessary for the management of chronic pain, including severe cancer pain, the procedure could be deemed medically unnecessary if the practice cannot show that it followed a series of steps before choosing an epidural injection.
Medicare guidelines instruct physicians to evaluate the patient thoroughly and to provide the modality most likely to establish or treat the presumptive diagnosis. If the first procedure fails to produce the desired effect and rules out that possibility, the provider may proceed to the next logical treatment.
In addition, the patient’s medical record should document the presence of radicular pain and the neuropathic diagnosis being treated. The record should establish the failure of conservative management and the fact that the patient is a poor surgical risk or does not wish to have surgery.
The policy leaves room for arbitrary decisions, such as which drugs or modalities should be used before moving to epidural injections. But AHCQR guidelines can fill in the details not included in carrier policies. In addition, proof that AHCQR guidelines were followed is the best defense against a denied claim during the appeal process, Gutgsell says.
The AHCQR (formerly called the Agency for Health Care Policy Research) recommends physicians follow these guidelines when determining the type and scope of pain therapy:
— An essential principle in using medications to manage cancer pain is to individualize the regimen to the patient.
— The simplest dosage schedules and least invasive pain management modalities should be used first.
— Pharmacological management of mild to moderate cancer pain should include an NSAID or acetaminophen, unless there is a contraindication.
— When pain persists or increases, an opioid should be added.
— Treatment of persistent or moderate to severe pain should be based on increasing the opioid potency or dose.
— Medications for persistent cancer-related pain should be administered on an around-the-clock basis with additional "as-needed" doses, because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain.
— Patients receiving opioid agonists should not be given a mixed agonist-antagonist, because doing so may precipitate a withdrawal syndrome and increase pain.
— Meperidine (J2175) should not be used if continued opioid use is anticipated.
— Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with addiction.
— The oral route is the preferred route of analgesic administration because it is the most convenient and cost-effective method of administration. When patients cannot take medications orally, rectal and transdermal routes should be considered because they are also relatively noninvasive.
— Intramuscular administration of drugs should be avoided because this route can be painful and inconvenient, and absorption is not reliable.
— Failure of maximal systemic doses of opioids and co-analgesics should precede the consideration of intraspinal analgesic systems.
— Because there is great inter-individual variation in susceptibility to opioid-induced side effects, clinicians should monitor for these potential side effects.
— Constipation is a common problem associated with long-term opioid administration and should be anticipated, treated prophylactically, and monitored constantly.
— Naloxone (J2310), when indicated for reversal of opioid-induced respiratory depression, should be titrated in doses that improve respiratory function but do not reverse analgesia. Placebos should not be used in the management of cancer pain.
— Patients should be given a written pain management plan.
— Communication about pain management should occur when a patient is transferred from one setting to another.
The above guidelines have particular significance for choosing the appropriate drug. With the growing number of pain drugs and the off-label use of drugs, choosing the appropriate drug can pose reimbursement problems because many policies do not mention use of drugs such as 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, Gutgsell says. This is especially important for expensive drugs such as pamidrinate, which can cost $600 to $1,200 for a single injection.
In the event of a payment denial, Gutgsell says data published in journals provide validation for drug choice. Guidelines, however, suggest that the physician consider other drugs, including less powerful drugs or less invasive modes of delivery.
In addition, the American Society of Clinical Oncology’s public policy and practice department recommends following Medicare regulations for off-label use of drugs and biologicals. Off-label use of drugs is covered when all of the following conditions 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 an immunization.
— The drug has not been determined by the FDA to be less than effective.
Following AHCQR guidelines will bolster medical necessity for invasive procedures, such as epidural injections and infusion pumps (codes E0779-E0791).
Following guidelines will keep practices in line with carrier policies that include these requirements:
— The patient’s history must indicate that he/she would not respond adequately to noninvasive methods of pain control, such as systemic opioids (including attempts to eliminate physical and behavioral abnormalities that 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.