Pain Codes targeted on the ‘not typically required’ list by ASA

On March 8th, 2011, posted in: Medical Coding by

Pain providers may see more denials this year. SI injections (27096), epidurals (62310-62319) paravertebral facet injections (64490-64495) and greater occipital nerve blocks (64405) are now designated as “Anesthesia Care Not typically required” in the American Society of Anesthesiologist (ASA) 2011 Crosswalk.

Many insurance carriers use the ASA crosswalk as their guide for linking procedures together. When the carrier sees the new designation for the anesthesia services, they may issue a denial. To achieve payment, you will need to prove services were medically necessary due to an underlying condition requiring the patient to be monitored throughout the service or a condition that prevented the patient from holding still or lying prone for the duration of the procedure.

Pain and anesthesia practices should look at local medical policies to determine if carriers deem the use of a second physician necessary to provide anesthesia during interventional pain management procedures. Just because you may not find a LCD (local carrier determination), doesn’t mean medical necessity isn’t an issue. LCD’s are often updated long after the fact and medical necessity is always the underlying issue for any patient, anytime and for every procedure.

One Medicare carrier (Care First) has issued this policy for monitored anesthesia care codes (01991-01992) during interventional pain management services.

“The patient’s medical condition or nature of the procedure requires the presence of a second physician represented by an anesthesiologist or qualified anesthesia provider to administer the sedation if utilized to manage the airway & vital signs, and to continually assess the patient for clinical problems and treat appropriately to ensure patient safety and comfort.”

“The presence of an underlying condition alone or a stable treatable condition is not sufficient evidence that monitored anesthesia care is medically reasonable and necessary.”

According to First Coast, some conditions that demonstrate medical necessity:

  • Co-morbidities such as pulmonary disease, cardiac disease, morbid obesity, severe sleep apnea
  • Inability to follow simple commands caused by developmental delay or dementia
  • Spasticity disorders that would make it difficult for the patient to lie still
  • Severe anxiety immediately prior to the procedure which may affect patient safety and comfort
  • The patient is a Medicare –eligible pediatric patient

A diagnosis alone will not prove medical necessity. The patient’s condition must be significant enough to impact the need to provide MAC (such as the patient being on medication or symptomatic, etc.). The presence of a stable, treated condition is not generally sufficient medical justification for MAC, First Coast writes. They go on to give an example:

“An otherwise healthy patient who suffers from senile dementia with delusional features (290.20) is scheduled for a single-level lumbar paravertebral face injection (64493). However, the patient is able to understand and follow instructions, holds still for the duration of the procedure and shows no signs or symptoms of unusual anxiety before the procedure. The carrier would issue a medical necessity denial for anesthesiologist’s services.

When you are scheduling the case, indicate the medical necessity to your scheduler. It may assist in the precertification process and potentially help with appealing the denial, if necessary.