Be Rightfully Reimbursed for Pain Management
Published on Sat Jul 01, 2000
Pain management has garnered increased attention recently. End-of-life care advocates have long criticized physicians, including oncologists, for not providing proper palliative care to their patients. This sentiment has been underscored by recent lawsuits for inadequate pain management, including a case involving an 85-year-old cancer patient.
With the growing concern over the quality of pain management, physicians are trying to catch up on the latest in palliative care, and many are still confused about how to get reimbursed for their pain management services. Nevertheless, they can be rightfully reimbursed if they attend to the details, such as validating medical necessity if they used an off-label drug, using the correct codes for the type of drug delivery system used and so forth.
Drug Choice and Reimbursement
Choosing the appropriate drug is also a challenge for many physicians. Basic pain-management drugs come in two forms: non-steroidal anti-inflammatory drugs, such as ibuprofen and aspirin; and opioids, such as morphine, fentanyl or codeine. In most cases, pain drugs are given orally. The remainder are administered intramuscular, subcutaneously, intravenously, intraspinal or intraventricular.
Medicare regulations mention common drugs, such as morphine, that can be used with infusion pumps for intractable pain. But the population of pain-management drugs is much greater, says Terry Gutgsell, MD, medical director of the Hospice of the Bluegrass in Lexington, Ky.
Some of the available drugs have primary uses outside palliative care, such as methadone (used to treat heroin addiction), J1230; ketamine (anesthesia); and pamidronate (bone resorption in metastatic breast cancer), J2430. These drugs are effective, but physicians have the burden of proving medical necessity, Gutgsell says. (This is especially important for expensive drugs like pamidronate, which can cost $600 to $1,200 for a single injection.)
Gutgsell advises physicians who plan to use an off-label drug to provide data published in journals and, when seeking advice from pain-management experts, to ask for published data to support the recommendation. Also, Laurie Lamar, RHIA, CCS, CTR, CSS-P, reimbursement specialist with the American Society of Clinical Oncology in Alexandria, Va., recommends following Medicare regulations for off-label use of drugs and biologicals. Oncologists can expect off-label drugs to be covered if all of the following criteria are met:
the drug meets the definition of drugs and biologicals;
the drug is the type that cannot be self-administered;
the drug meets all the general requirement for coverage of items as incident to a physicians services;
the drugs are reasonable and necessary for the diagnosis or treatment of the illness or injury for which they are administered according to accepted standards of medical practice;
the drugs are not excluded as immunizations;
the drug has not been determined by the FDA to be less than effective.
Injection Coding
In the rare instance that [...]
