Anesthesia

[steveadlman]

I have a client that will be getting a pain block and was told Medicare will not cover the anesthesia for the pain block. Is it because Medicare does not cover it or because the reimbursement rate is too low?

 

[Duaine]

Does Medicare cover nerve block?


Medicare Coverage for Genicular Nerve Block

Medicare will likely pay 80 percent of the Medicare-approved final amount, and you are responsible for the remaining 20 percent of that amount. You are also responsible for a copayment if the exam is done in a hospital outpatient setting.
https://www.medicare.org/articles/does-medicare-cover-genicular-nerve-block/
Does Medicare pay for pain injections?


Per the standard Medicare guidelines, cortisone injections for lower back pain usually receive coverage without prior authorization through Medicare Part B. However, different doses have different costs. So, make sure to ask your doctor about the allowable amount for each procedure

 

[straightnochaser]

I have a client that will be getting a pain block and was told Medicare will not cover the anesthesia for the pain block. Is it because Medicare does not cover it or because the reimbursement rate is too low?

Medicare Part A covers anesthesia services if you’re an inpatient in a hospital.

Medicare Part B covers anesthesia services if you’re an outpatient in a hospital or a patient in a freestanding ambulatory surgical center.

 

[LostDollar]

I have a client that will be getting a pain block and was told Medicare will not cover the anesthesia for the pain block. Is it because Medicare does not cover it or because the reimbursement rate is too low?

I thought CMS' opinion on Medical Necessity, not a Medicare approved reimbursement level, was the criterion for Medicare coverage of a service or item.

 

[rousemark]

I have a client that will be getting a pain block and was told Medicare will not cover the anesthesia for the pain block. Is it because Medicare does not cover it or because the reimbursement rate is too low?

Medicare used to pay for the anesthesia but quit covering it a few years ago. They take the stance that it is not required. My wife has to have the blocks done and she said whoever made that ruling has never had to have one.

 

[somarco]

Medicare used to pay for the anesthesia but quit covering it a few years ago. They take the stance that it is not required. My wife has to have the blocks done and she said whoever made that ruling has never had to have one.

Not doubting your word, but what was the code on your MSN? (Why did they deny it?)

 

[rousemark]

Not doubting your word, but what was the code on your MSN? (Why did they deny it?)

I do not know the code. However, Charlotte's pain specialist told us it was no longer covered by Medicare. Medicare had paid for the previous ones but did not payvfor her last two. It was not covered because the anesthesia was not a necessary procedure. They did pay for the block itself.

 

[somarco]

I do not know the code. However, Charlotte's pain specialist told us it was no longer covered by Medicare. Medicare had paid for the previous ones but did not payvfor her last two. It was not covered because the anesthesia was not a necessary procedure. They did pay for the block itself.

Did you appeal the decision? You have 60 days from the date of the denial to appeal.

Seems like the doc did not properly code the claim. The explanation does not make sense.

The anesthesia service must be associated with the underlying medical or surgical service.
https://www.medicare.gov/coverage/anesthesia

 

[somarco]

This is interesting . . .


New Medicare local coverage determinations (LCD) may hinder the ability to be paid for anesthesia services during Epidural Steroid Injections (ESI) for pain management. The LCDs for several Medicare Administrative Contractors (MACs), like WPS GHA’s L39054 for Indiana, went into effect in late 2021, and others are being rolled out in 2022. They replace and expand upon the retired LCDs for Lumbar Epidural Injections (like L36521 for WPS GHA).

The retired LCDs indicated among their requirements that “local anesthesia or minimal conscious sedation may be appropriate” and the “use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary.” However, the new LCDs do not include that language, and instead, say among the limitations that

The use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice.
[EXTERNAL LINK] - Anesthesia Restrictions When Billing Medicare for Epidural Steroid Injections - CIPROMS, Inc.


It appears that CMS believes anesthesia in these situations was overused but will allow anesthesia on a case by case situation subject to documentation supporting the medical necessity and proper coding.



Providers also must follow certain documentation guidelines based on the new LCD. In addition to standard best practices, like writing legibly and maintaining all documentation within the patient’s medical record, CMS also requires that

• The procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.
• Films that adequately document (minimum of 2 views) final needle position and contrast flow should be retained and made available upon request.

Also, as mentioned above, if the physician believes the patient’s condition warrants the use of Moderate or Deep Sedation, General Anesthesia, or Monitored Anesthesia Care (MAC), the documentation should clearly establish the need for such sedation in the specific patient.
op. cit.