Bulletproof Pain Management Claims:
Follow AHRQ Guidelines
Published on Mon Oct 01, 2001
Pain management payment policies can be vague, and claims may lead to denials despite an oncology practice's efforts to follow a Medicare carrier's medical review policy. If, however, practices follow cancer pain guidelines from the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research, AHCPR), they can make their pain management claims bulletproof. This is achieved by using standards that not only mirror Medicare policy but also provide a more detailed process for determining medical necessity.
"If you follow AHRQ guidelines and document each item, adhering to the steps 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, including oncologists.
AHRQ guidelines have some drawbacks, says Michael Ashburn, MD, director of the Pain Center at the University of Utah's Health Sciences Center. Most notably, the guidelines are becoming outdated with every new pain drug that becomes available. However, he says the guidelines can be used to provide evidence of sound medical decision-making and can serve as a strong argument for medical necessity when claims are questioned by Medicare carriers.
Policies Leave Room for Interpretation
How can practices be sure the drugs and procedures they choose will be reimbursed? For Medicare, local medical review policies (LMRPs) determine whether a particular pain management regimen will be reimbursed. In most cases LMRPs have themes that are similar to AHRQ guidelines.
A number of pain management options are available to treat cancer pain, ranging from nonsteroidal anti-inflammatory drugs to opioids. And there are a variety of modalities, including oral drugs, injections and infusions.
For example, use 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]) to report epidural injections.
Although these injections and nerve blocks are considered 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 are very ambiguous and instruct physicians to evaluate the patient thoroughly and to provide the modality most likely to establish or treat the presumptive diagnosis. They say that if the first procedure fails to produce the desired effect and rules out that possibility, the provider may proceed to the next logical treatment. These are unclear instructions.
Also, document in the patient's medical record the presence of radicular pain and the neuropathic diagnosis being treated. Establish the [...]
