Medicare Coverage Policies for Chronic and Acute Pain

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Medicare Coverage Policies for Chronic and
Acute Pain
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Medicare Coverage Policies for Chronic and Acute
Pain
Medicare under title XVIII of the Social Security
Act, includes traditional or original
Medicare benefits administered in Part A
(hospital and other inpatient facility services)
and Part B (physician and other outpatient
facility services, and certain drugs) Part C
(Medicare Advantage), and the optional
prescription drug benefit administered by private
plans under Part D. In this article we focussed
on Part A and B Medicare coverage policies for
chronic and acute pain. Inpatient and Outpatient
Prospective Payment Systems Medicare generally
pays under Part A for covered inpatient hospital
services furnished during an inpatient hospital
stay based on payment rates set under the
inpatient prospective payment system (IPPS).
Under the IPPS, CMS sets bundled payment rates to
reflect average costs incurred by hospitals in
providing care, generally comprising all items
and services supplied by the hospital during the
inpatient stay, including any drugs or other
therapies provided for the purpose of managing
pain. Under the IPPS, CMS annually reviews and
assigns discharges to Medicare severity-diagnosis
related groups (MS-DRGs), which associate
patients with similar clinical conditions who are
expected to require similar amounts of hospital
resources. Medicare generally pays under Part B
for covered outpatient department services
furnished to beneficiaries in hospital outpatient
departments at amounts set under the outpatient
prospective payment system (OPPS). Under the
OPPS, CMS annually classifies services into
ambulatory payment classifications (APCs) on the
basis of clinical and cost similarity.
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Medicare Coverage Policies for Chronic and Acute
Pain
All services included in an APC have the same
payment rate. Under the OPPS, certain drugs and
biologicals are packaged into APCs if their
per-day cost is below a certain threshold or if
they fit into one of the categories of drugs that
are packaged (such as drugs that function as
supplies in surgical or diagnostic procedures).
Drugs and biologicals are also packaged if they
are billed with a comprehensive APC service.
Drugs that are not packaged under the OPPS drug
packaging policies are paid separately, generally
at average sales price (ASP) 6. Physician Fee
Schedule The Medicare Physician Fee Schedule
(PFS) governs payment for physician and
non-physician practitioner services under Part B.
Payments under the PFS are based on national
uniform relative value units (RVUs) that account
for the relative resources used in furnishing a
service and fall into three categories of
resources work, practice expense, and
malpractice expense. CMS also annually
incorporates geographic adjustments to reflect
variations in the costs of furnishing services in
different geographic areas. The conversion factor
is a national dollar amount that is multiplied by
the total geographically adjusted RVU to
determine the Medicare-allowed payment amount for
a specific physician service. Some non-drug
therapies for pain management are covered as
clinician services under the PFS. These therapies
can be considered singularly or combined with
other therapies as part of a multimodal approach
to the management of chronic and acute pain,
based on individual needs.
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Medicare Coverage Policies for Chronic and Acute
Pain
Restorative Therapies Medicare Part B covers
outpatient physical and occupational therapy at
80 percent of the Medicare approved amount, which
for some beneficiaries may create a disincentive
due to higher out-of-pocket costs for the patient
as compared to drug costs. Previously, the
Medicare statute-limited the amount of coverage
for outpatient therapy available to beneficiaries
in a calendar year, but that cap was removed
beginning in 2019. Although determining the
efficacy of some forms of restorative therapy
requires additional study, the Pain Management
Best Practices Inter-Agency Task Force (PMTF)
report recommends that there should be minimal
barriers to accessing modalities for which clear
indications of benefits in the treatment of
chronic pain exist as part of a recommended
multidisciplinary approach. Legion Health Care
Solutions is a leading medical billing company
providing complete billing and coding services.
For detailed understanding of Medicare coverage
policies for chronic and acute pain we referred
MS Action Plan to Enhance Prevention and
Treatment for Opioid Use Disorder, you can visit
link for detailed understanding. For any
assistance in pain management medical billing,
contact us at 727-475-1834 or email us at
info_at_legionhealthcaresolutions.com
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