General
Chapter 1
Section 10
Postoperative
Pain Management - Epidural Analgesia
Issue Date: February 21, 1995
Copyright: CPT only © 2006 American Medical
Association (or such other date of publication of CPT).
All Rights Reserved.
Revision:
1.0 APPLICABILITY
This policy is mandatory for
reimbursement of services provided by either network or non-network providers.
However, alternative network reimbursement methodologies are permitted
when approved by the Defense Health Agency (DHA) and specifically
included in the network provider agreement.
2.0 ISSUE
How are physicians to be reimbursed
for postoperative pain management?
3.0 BACKGROUND
3.1 Postoperative
pain management consisting mainly of the intramuscular (IM) and/or intravenous
(IV) administration of patient controlled analgesia (PCA) is considered
a part of the global charge for the surgery. The administration
of epidural analgesia is a specialized technique that can only be
provided by a specially trained physician. It includes the following
services:
• Placement of the epidural catheter
(an invasive procedure requiring about 20 minutes).
• Mixing of the epidural analgesia
infusion.
• Programming and initiation
of infusion pump.
• Completion of detailed epidural
analgesia orders.
• Daily monitoring and adjustment
of epidural and infusion pump.
• Twenty-four hour availability/coverage
to physically respond to problems/complications.
3.2 Since postoperative epidural
analgesia care represents a level of services above that of routine postoperative
pain relief provided by physicians, it is allowed outside the global
surgical fee subject to the following reimbursement guidelines.
4.0 POLICY
4.1 Payment
of postoperative pain management outside the global surgical fee
is only allowed for epidural analgesia care provided and billed
by a physician. TRICARE will pay the physician for:
4.1.1 Insertion
of the epidural catheter (CPT procedure codes 62278 and 62279 -
epidural, lumbar or caudal, continuous) on the day of the surgery;
and
4.1.2 Daily hospital management of
epidural drug administration (CPT procedure code 01996) following
the day of surgery (not the day of surgery).
4.2 The physician is only allowed
to bill one pain management procedure code (CPT procedure code 01996)
per day. The procedure includes all visits and contacts during the
24-hour time period to adjust the dosage and to maintain a functioning
catheter.
4.3 Daily hospital management of
epidural drug administration will be paid up to 3 days following the
day of surgery. Additional management services may be allowed at
the discretion of the contractor based on best commercial practices.
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