Anesthesia Coding Alert

A common pain-management trend is to allow patients to control the amount of analgesia they receive after certain procedures. This is particularly true for surgical or obstetrical patients, and sometimes even pediatric patients. Its a service that has been used for a number of years, but anesthesia coders say its becoming more and more popular. In many instances, reimbursement for patient-controlled analgesia (PCA) is being denied. To determine whether to spend the time filing for reimbursement, know your carriers policies and the terms of your contracts.

Proponents of PCA say it allows patients to have more control of their situation, and provides a more accurate medication dosage since only the patient knows when or how much pain he or she is in. The patient pushes a button to deliver a measured amount of medication intravenously. The physician prescribes a maximum dose for a particular time period, so the patient cannot administer more medication than the physician would recommend.

Deciding Whether to File

With more physicians agreeing with the concept and many patients responding favorably to it, the question for anesthesia coders is whether they should attempt to be reimbursed for PCA once its been administered or count it as a loss and write it off up front.

Medicare will not reimburse for PCA in any way, says Scott Groudine, MD, chair of the government, legal and economics affairs committee of the New York State Anesthesia Society. Reimbursement can really be hit or miss, at least in New York. Some of our local HMOs will reimburse for one or two days of follow-up PCA after a procedure, but that depends on the contract we have with them.

Reimbursement for PCA should always be considered when youre negotiating contracts with different carriers, advises Dana Goodridge, director of operations at Comprehensive Medical Management, a Newport, Ky., firm that specializes in medical billing. We work with clients across the country, and several national carriers such as Aetna/US Healthcare, Humana, Cigna, United Healthcare and Anthem will usually reimburse for PCA. Medicaid will reimburse in some states but not in others, so its important to know what your local policy is. For other carriers, review your contracts and ask specific questions about whether PCA is covered.

If You Decide to File

PCA charges are entered separately from the professional fee for the service. The best way to code for this reimbursement depends on how the anesthesia group handles the service. Some practices or hospitals have a designated acute pain service team that handles all PCA follow-up care. In this case, PCA services are billed [...]