Anesthesia Coding Alert

The local medical review policies for Regence Blue Cross Blue Shield, Utah's Part B Medicare carrier, state that intrathecal pain therapy may be used for the management of chronic intractable pain, particularly that which is secondary to carcinoma (primary or metastatic), when it is not controlled by less invasive techniques. As with all covered procedures, medical necessity must be established and the treatment must match the diagnosis.

Regence's coding guidelines state that when the cause of pain is malignancy, the diagnosis code for the malignancy should be used. Among the covered ICD-9 codes listed in the LMRP are 170.2 (Malignant neoplasm of the vertebral column, excluding sacrum and coccyx), 170.3 (Malignant neoplasm of ribs, sternum, and clavicle), and 171.7 (Malignant neoplasm of trunk, unspecified).

In addition to the CPT codes listed previously, Regence's LMRP also lists two reimbursable drug codes: J2270 (Injection, morphine sulfate, up to 10 mg) and J2271 (Injection, morphine sulfate, 100 mg).

"These drugs carry special coverage instructions," says Kelly Dennis CPC, EFPM, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla. Dennis says Florida's Part B Medicare carrier specifies that supplies and drugs that are furnished for an implantable infusion pump must be prescribed by the patient's physician and documented with the initial claim. Further, they require that a completed certificate of medical necessity (CMN), with the prescribing physician's original signature, be submitted.

The CMN is valid for up to six months; if the period of medical necessity is longer than six months, the CMN must be renewed. The CMN is also required when the patient's prescription is revised or renewed.

She advises coders and billers to ask their local Medicare and private carriers for guidelines for submitting drugs for reimbursement, as well as coding and documentation guidelines for intrathecal pain treatment in general. "Some carriers will consider claims (on an individual basis) for treatment with additional analgesics," Dennis says.

Intrathecal Trials

Regence's LMRP requires that a physician certification of life expectancy of three months or more be noted in the patient's medical record and that the patient has been unresponsive to less invasive medical therapy. Patients should also have completed a trial of intrathecal administration.

"The LMRPs for many contractors state that the trial injection should not be coded under 62350," Dennis says. Rather, coders should use the following, depending on the anatomic site and modality:

Studies by the American Cancer Society estimate that 90 percent of cancer pain can be relieved with oral opiates. For the remaining 10 percent of patients, interventional methods such as intrathecal pain therapy are effective in relieving pain.

Columbus says that the heart of cancer pain management is determining which therapy or combination of therapies works for each patient: "As each patient is unique, so too are their pain management needs. The key steps in ensuring adequate pain control are an accurate pain diagnosis; appropriate use of surgical, pharmacological, and radiation interventions; proper application of noninvasive and invasive pain relief techniques; and adequate and on-going follow-up to adjust the treatment approach to the patient's changing clinical condition."