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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
General
Chapter 1
Section 10
Postoperative Pain Management - Epidural Analgesia
Issue Date:  February 21, 1995
Authority:  32 CFR 199.4(c)(2)
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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