ne of the many values of ASA membership is the very hard work that its staff, officers and committee members apply to pain practice management issues. Notably the staff and officers closely cooperate with other organizations that represent pain medicine physicians. This work provides a bulwark for the pain medicine specialist against the sometimes irrational tides of regulation and payer policies that seem to surge daily against our practices and our patients.

The committees on Economics and Pain Medicine and the ASA staff and officers have worked in concert this past year on a number of issues important to ASA members’ pain medicine practice management.

1. Coding Issues: New technology and practice patterns require ongoing evaluation of the codes we use to describe the services we provide to our patients. This year ASA has considered the codes applied to paravertebral nerve blockade, kyphoplasty, vertebroplasty, selective nerve root injection and “pulsed” radio-frequency denervation. The two committees and staff have worked to create the necessary information to usher new codes or re-appraisals of existing codes through the very complex process of approval via the American Medical Association (AMA) Current Procedural Terminology™ (CPT) Editorial Panel and the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), in accordance with Medicare’s Resource-Based Relative Value Scale (RBRVS) system, the determinant of most physician payment.

The key to successful code acceptance is to present to the CPT Editorial Panel a cogent argument describing need and an accurate definition and indications. Once a new code or revision is approved, a proper value must be assigned to it. Valuation requires that the sponsoring specialty society canvass its members to glean the facts regarding realistic work values and practice expenses associated with each procedure. ASA members can greatly contribute to these efforts by participating in surveys when asked to do so. A society can make a stronger argument to the RUC when it has a large survey response.

There is a congressional mandate that RBRVS physician work values be reviewed at least every five years. The third Five-Year Review is under way as this article is written, and ASA has joined the American Academy of Pain Medicine, the North American Spine Society and the American Association of Neurological Surgeons/Congress of Neurological Surgeons in requesting a re-evaluation of the work associated with spinal cord stimulator placement as well as intrathecal and epidural pump implantation. By the time you read this, we hope that the members have responded in large numbers to the surveys that were distributed, or the data may carry little value when the codes are reviewed by the RUC.

2. Review and comment on regional Centers for Medicare & Medicaid Services (CMS) carrier reimbursement policies: When new policies or decisions are adopted by a local Medicare carrier, or if decisions are pondered at the Carrier Advisory Committee (CAC), it may be helpful to the practitioner, the carrier and the CAC if ASA provides perspective on reimbursement policy. In that situation, the ASA staff works with the local medical community, especially the ASA CAC member. An ASA member serves on every CAC, and ASA has advised all state societies, who choose the CAC representatives, to ensure that either the principal or alternate representative has an active pain practice. Every member should, however, monitor his or her own local carrier’s policies when they are in the development stage <www.cms.hhs.gov/mcd/search.asp>. If there is an issue of significance, please call the ASA Washington Office at (202) 289-2222 to alert either Assistant Director of Governmental Affairs (Regulatory) Karin Bierstein or Coding and Reimbursement Analyst Sharon Merrick, who spend all of their free time reading anesthetic payment policy literature.

This past year, ASA has advocated on behalf of pain medicine practice in the private and governmental realms, including issues regarding somatic nerve block policies by the CMS carriers Noridian and Empire and edits of the McKesson software used by private payers to help determine payment policies. The ASA Washington Office also has worked with Administar, administrator of the National Correct Coding Initiative (NCCI), which is the software used by Medicare carriers regarding payments for pain and anesthesia. NCCI edits are updated quarterly and are available on the CMS Web site at <www.cms.hhs.gov/physicians/cciedits/default.asp>.

Other topics monitored by the committees include CPT Assistant advisories on facet injections and payer concerns about “acceptable” lifetime dosage of steroids in the epidural space, frequency of injection therapy for complex regional pain syndrome, pulsed versus “original” radio-frequency ablation coding, ultrasound guidance for regional anesthetic placement and the use of sedation for facet injections.

3. Pay for Performance: This initiative, recently embraced by CMS and other payers, would eventually link health care provider payment to outcome measures. Presently it appears that indicators of process (how care is delivered) rather than of outcome (how well patients responded) will be the monitored and “rewarded” measurements. Eventually it is expected, however, that actual clinical outcomes will be linked to the magnitude of provider reimbursement.

While provider skepticism is understandable, this initiative is moving forward, and we are challenged to help guide the choice of measurements toward those most likely to fulfill two requirements:

• The variable’s measurement will not decrease the cost of “unnecessary” care.

• The variable has a valid reflection to patient care quality.

It will be important for ASA and each of its members to be proactive in helping to develop these measures in concert with payers and CMS. Ms. Bierstein and Director of Governmental Affairs and General Counsel Ronald Szabat in ASA’s Washington Office are very involved in this issue and can answer ASA members’ questions on this topic.

In summary use the resources cited above and be alert to changes in the economics surrounding pain practice in your area. If you have any concerns, contact ASA, an emphatic advocate for the patients and practices of the anesthesiologist who is involved in pain medicine.

The author acknowledges without embarrassment that most of the accuracies and useful information in this article were ghostwritten by Ms. Bierstein and Ms. Merrick. Any inaccuracies are his own.

Douglas G. Merrill, M.D., is Staff Anesthesiologist, Virginia Mason Clinic, Seattle, Washington.