Postoperative Pain Management and Palliative Therapy
Effective for services provided on or after July 1, 2001, postoperative pain management and selective palliative therapy provided by anesthesiologists are covered Medicaid services. Pain management must be related to the immediate post operative period or a catastrophic or terminal illness where palliative therapy is indicated. The Primary Care Physician or surgeon must request or order pain services to be provided by an anesthesiologist. Prior authorization is not required.
Specific conditions for coverage are described below.
A. Definitions
• Epidural Analgesia means placement of an epidural catheter, injection of anesthetic or therapeutic
substances, and daily management of drug therapy.
• Nerve Block or single epidural injection is used to treat acute pain. Often pain management
provided in this manner provides an opportunity to treat the pain more effectively, improves pain
management
• Pain Relief is reduction of the level of pain, not elimination of pain.
• Palliative Therapy means therapy that relieves symptoms of illness or a disorder but does not
promote a cure. An example of palliative therapy is treatment for terminal illness or complex
medical problems where severe pain is a significant factor.
• Patient Controlled Analgesia (PCA) means intravenous placement of a catheter for self administration of therapeutic drugs through an infusion device. PCA includes daily management
and follow-up services by the anesthesiologist, related to the drug therapy.
B. Epidural analgesia may be provided by single injection or continuous infusion. Sometimes placement of an epidural catheter prior to surgery is preferred because the patient can report any accompanying paresthesias and the catheter can be tested prior to surgery. The epidural catheter placed during the primary anesthesia procedure becomes part of the global anesthesia procedure. Since there are occasions, especially in pediatrics, when it is best to complete the epidural procedure for postoperative pain management during the primary anesthesia service, Medicaid will pay for the single block injection or epidural catheter placement at one-half the fee schedule rate when the procedure is completed within the primary anesthesia service during surgery. The single block or epidural injection for postoperative pain management must be administered separately from the primary anesthesia (before or after the surgery) for full fee schedule payment of the code. Placement of the PCA infusion set up will occur in the recovery room following surgery.
1. Submit the claim for initiation of postoperative pain management services on a CMS-1500 claim
form separate from the general anesthesia claim. The same date of service as the anesthesia
administration may be used. Submit documentation of the primary anesthesia record, with
documentation related to the injection service for postoperative pain management, for review.
2. Submit a claim for postoperative, daily pain management (code 01996) as of the day following
placement of the catheter or set up of the PCA. Submit a CMS-1500 claim separate from the anesthesia for the surgical procedure, and separate from the charge for initial placement of
epidural or set-up of PCA charge. Use CPT or ASA codes on the claim, depending on the route
of administration. No other codes will be accepted. There is one exception to the payment of
code 01996 on the same date as the primary anesthesia procedure. Sometimes the epidural
catheter for postoperative pain management may be placed at the time of surgery by the surgeon
because he/she is operating on the back. This will occur only in laminectomy or decompression
(CPT codes 63001-63290) and spinal lesion or deformity (CPT codes 22100-22852). Since the
anesthesiologist does not place the epidural catheter but does manage the catheter and
medication administration the day of surgery, a daily visit code (01996) will be allowed in addition to the general anesthesia on the day of surgery. The catheter is left in place for three days or less
because the patient usually has recovered sufficiently to allow removal. Documentation must
support daily pain management code 01996.
3. For reimbursement of postoperative pain management, the postoperative injection or epidural
service must be submitted with modifier 59. The time of placement of the epidural catheter or
block injection must be clearly documented in the medical record. Failure to document the
services to indicate the procedure was complete prior to surgery, soon after surgery in the
postoperative period, or during the primary anesthesia procedure, will result in a denial of
reimbursement for service.
4. Anesthesia service such as code 00630 delivered for chronic pain management is a non-covered
service. The primary anesthesia code 00630 and a series of block, epidural, and/or trigger point
injections for chronic pain management are not payable on the same date of service. Chronic
pain management is only covered with prior authorization, see criteria 45. Trigger point injections
and epidural/block injections for pain management are subject to the limitations described in
criteria 34 A&B.
C. Use the approved postoperative pain management codes listed below. Submit a CMS-1500 claim separate from the general anesthesia claim.
1. Epidural or Nerve Block Analgesia by continuous infusion
* 62318 Injection, including catheter placement, continuous infusion or intermittent bolus, of therapeutic
substances, epidural or subarachnoid; cervical or thoracic.
* 62319 Injection, including catheter placement, continuous infusion or intermittent bolus, of therapeutic substances; lumbar, sacral (caudal).
*64416 Injection, anesthetic agent plexus, continuous infusion by catheter
*64446 Injection, anesthetic agent, sciatic nerve, continuous infusion by catheter
*64448 Injection, anesthetic agent, sciatic nerve, continuous infusion by catheter
*Select one of these codes for neuraxial narcotic injections or placement of the catheter when the service is not part of the general anesthetic. Payment will be made only once during an episode of care. Reimbursement for post-operative daily pain management is:
01996 Daily follow-up and management of epidural or nerve block analgesia by continuous or
intermittent infusion. Units will be attached to this code but no time. (A “0″ is not an appropriate
unit to use in this field.) Payment will be made only once daily beginning the day after the
surgical procedure unless the epidural catheter has been placed by the surgeon, see B.2 above.
2. Epidural or Nerve Block Analgesia by Single injection
*62310 Injection, single (not via indwelling catheter) not including neurolytic substances, with
or without contrast, epidural or subarachnoid; cervical or thoracic.
*62311 Injection, single (not via indwelling catheter) not including neurolytic substances, with
or without contrast, epidural or subarachnoid, lumbar, sacral (caudal)
*64415 Injection, anesthetic agent, brachial plexus, single
*64417 Injection, anesthetic agent; axillary nerve, single
*64445 Injection, anesthetic agent; sciatic nerve, single
*64447 Injection, anesthetic agent; femoral nerve, single
*64450 Injection, anesthetic agent; other peripheral nerve or branch
*Select one of these codes for a single epidural or nerve block injection whose primary purpose is for postoperative pain, and unrelated to anesthesia for surgery. Payment will only be made once during an episode of care. Payment should not be denied as part of another service.
3. Patient Controlled Analgesia (PCA)
* 99231-24 Subsequent Hospital Care
* 99232-24 Subsequent Hospital Care
* Select one of these codes for the initial set-up and placement of the PCA. Payment should not be
denied as inappropriate or part of another service. When associated with pain management, the 24
modifier will be added to trigger the edit for adjudication review. The subsequent hospital care code at the appropriate level of service may be billed daily as long as medical record documentation supports management of the PCA.
4. Terminal Illness or Complex Medical Problem Management
Pain management for a terminal illness or complex medical problem become very individualized and
dependent on the condition and needs of the patient. For the terminally ill, palliative care for comfort may be the major need. As always, such care can be provided through the primary care physician and family assistance, through appropriate home health service or as part of an inpatient admission for general treatment or terminal care of the medical condition. The primary care physician remains ultimately responsible, but when the patient’s condition reaches the point that assistance is needed, the primary care physician can provide orders or referral to a pain management specialist who can use this protocol to place lines and provide daily management of the necessary medications.
