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May 1998
Volume 62 |
Number 5
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| Payment Guidelines
for Chronic Pain Reimbursement |
Michael A. Ashburn, M.D.
In order to control costs, many payers are in the process of
establishing payment guidelines regarding what medical services
they will pay for and under what circumstances they will pay for
these services. These guidelines have a daily impact on the care
provided to individuals with pain.
In the past, physicians have been reluctant to participate
in the development of payment guidelines, recognizing that such
guidelines will restrict the circumstances under which some services
may be provided. However, we are now faced with the reality that
payment guidelines will be created and enforced, regardless of
our willingness to assist in their development.
Last year, the American Pain Society (APS) and the American
Academy of Pain Medicine (AAPM) submitted suggestions for revision
of two proposed reimbursement guidelines made public by Medicare
intermediaries in Missouri and Connecticut. The proposed guidelines
established criteria for the behavioral assessment and therapy
of the chronic pain patient as well as for multiple pain management
procedures.
Frank R. Mohs, M.D., Medicare Medical Director of General
American, St. Louis, Missouri, released a proposed guideline that
established guidelines for when an individual may receive behavioral
assessment and therapy for chronic pain management. The guideline
established specific ICD-9 diagnosis codes under which a patient
could receive therapy and excluded payment for individuals that
did not fit within established criteria. In addition, the guideline
excluded payment for biofeedback as a specific treatment for any
type of headache.
A second proposed guideline was released by Arif Toor, M.D.,
Medicare Medical Director of United HealthCare, Meriden, Connecticut.
As did the St. Louis guideline, this guideline established criteria
for the behavioral evaluation of the chronic pain patient, but also
established guidelines for multimodal pain therapy and related procedures
[Table 1]. The proposed guidelines were extensive, 75 pages in length.
Table 1
United HealthCare Medicare Part B Local Medical Review Policies
for the Management of Chronic Pain
| Policy Number |
Description |
| 95010A |
Evaluation & management |
| 95010B |
Epidural injection |
| 95010C |
Sacroiliac joint injection |
| 95010D |
Trigger point injections |
| 95010E |
Transcutaneous electrical nerve stimulation |
| 95010F |
Percutaneous peripheral electrical nerve stimulation |
| 95010G |
Implanted peripheral electrical nerve stimulation |
| 95010H |
Dorsal column stimulators |
| 95010I |
Removal/revision of implanted extra/intracranial
neurostimulator; Electrodes/pulse generator |
| 95010J |
Deep brain stimulation |
| 95010ZZ |
Nerve block |
| 95010K |
Paravertebral nerve block |
| 95010L |
Facet joint block |
| 95010M |
Facet joint denervation |
| 95010N |
Intercostal nerve blocks/neurolysis |
| 95010O |
Greater occipital nerve block |
| 95010P |
Suprascapular nerve injection |
| 95010Q |
Sympathetic blocks |
| 95010R |
Implanted pumps for intrathecal opioid infusions |
| 95010S |
Behavioral assessment |
| 95010T |
Patient-controlled analgesia |
APS and AAPM sent a joint letter suggesting extensive
revision of the Connecticut intermediary guideline. The APS/AAPM
response was 20 pages in length and included suggestions for changes
in virtually every section of the proposed guideline. Specific
suggestions from individuals, expert in the use of the specific
procedures addressed, were included in the response. Where possible,
the APS/AAPM response was supported by scientific evidence published
in peer-reviewed journals.
In response to the proposed guidelines on the behavioral
management of chronic pain, the APS and AAPM made numerous suggestions
to move the proposed guidelines toward recognizing the importance
of interdisciplinary pain management. The response strongly supported
the role of psychological evaluation and therapy of the chronic
pain patient, stating, "In an interdisciplinary pain management
patient care model, psychological evaluation (and therapy) is
a vital portion of the patient's initial evaluation." The response
also objected to the exclusion of biofeedback for the treatment
of headache, stating, "There is ample evidence in a number of
well-controlled behavioral studies that biofeedback is effective
in the management of chronic pain, including headache."
The ASA Committee on Pain Management is attempting to
become involved in the development of payment guidelines, which
may have an impact on the practice of pain medicine. The committee
anticipates working with other professional organizations to assist
in the development of payment guidelines that are based, whenever
possible, on scientific fact. The committee believes that review
of a draft guideline with an opportunity for input early is better
than attempting to reverse a bad guideline after its implementation.
The committee hopes to develop a process for review and comment
by interested members of ASA.
ASA has been informed that the Medicare Medical Directors
have established a Chronic Pain Management Work Group to review
locally prepared guidelines prior to considering these guidelines
for adoption nationally. ASA has asked for the opportunity to nominate
a representative to work with this group or to participate in the
review of any draft policies created by the group. No response to
the request has been received to date.
Michael A. Ashburn, M.D., is Professor
and Vice Chair, Department of Anesthesiology, and Medical Director,
Pain Management Center, University of Utah Health Sciences Center,
Salt Lake City, Utah.
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