Oncology & Hematology Coding Alert

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 Most notably, the guidelines are becoming outdated with every new pain drug that becomes available.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 failure of conservative management and that the patient is a candidate for surgery, but that the option of surgery is unacceptable to the patient or the patient is a poor surgical risk.
  
The policy leaves room for arbitrary decisions such as which drugs or modalities should be used before moving to epidural injections. However, AHRQ guidelines can fill in the details not included in carrier policies. Also, proof that AHRQ guidelines were followed is the best defense against a denied claim during the appeal, Gutgsell says. Document the proof in the patient's record.

 
The guidelines listed on this page have particular significance for choosing the appropriate drug. With the growing number of pain drugs and the off-label use of them, choosing the appropriate one can pose reimburse-ment problems. Many policies do not mention use of drugs such as methadone (used to treat heroin addiction), J1230; ketamine (anesthesia); and pamidronate (bone resorption in metastatic breast cancer), J2430.
 
While these drugs are effective, physicians must provide medical necessity, Gutgsell says. This is especially important for expensive drugs like pamidronate, which can cost $600 to $1,200 for a single injection.
 
In the event of a denial, Gutgsell says, data published in journals such as the American Journal of Medicine or the Journal of Clinical Oncology provide validation for drug choice. Guidelines, however, show that the physician considered other options, including less powerful drugs or less invasive modes of delivery.
 
The American Society of Clinical Oncology's public policy and practice department recommends following Medicare regulations for off-label use of drugs and biologicals. Off-label use of drugs is covered when all of the following are met. The drug:
 

meets the definition of drugs and biologicals;
 

is the type that cannot be self-administered;
 

meets all the general requirement for coverage of items as incident to a physician's services;
 

is 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;
 

is not excluded as an immunization;
 

has not been determined by the FDA to be less than effective.
 
Following AHRQ guidelines will also help prove medical necessity for invasive procedures such as epidural injections and keep practices in line with carrier policies that require:
 

the patient's history must indicate that he or she would not respond adequately to noninvasive methods of pain control, such as systemic opioids (including attempts to eliminate physical and behavioral abnormalities that may cause an exaggerated reaction to pain);
 

a preliminary trial of intraspinal opioid drug administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate adequately acceptable pain relief and degree of side effects (including effects on the activities of daily living) and patient acceptance.