TMPPM 2008 > Texas Medicaid Services > Physician > Procedures and Services

36.4.3.9 Pain Management

Acute pain is defined as pain caused by occurrences such as trauma, a surgical procedure, or a medical disorder manifested by increased heart rate, increased blood pressure, increased respiratory rate, shallow respirations, agitation or restlessness, facial grimace, or splinting.

Chronic pain is defined as persistent, often lasting more than six months; symptoms are manifested similarly to that of acute pain.

Postoperative refers to the time frame immediately following a surgical procedure in which a catheter is maintained in the epidural or subarachnoid space for the duration of the infusion of pain medication.

Epidural and Subarachnoid Infusion (not including Labor and Delivery)

Epidural and subarachnoid infusion for pain management is payable for acute, chronic, and postoperative pain management. Procedure code 1-01996 should be reported as a type of service (TOS) 1 (medical) instead of a TOS 7 (anesthesia).

Procedure code 1-01996 is limited to once per day and is denied when billed on the same day as a surgical/anesthesia procedure (TOS 2, 7, and 8). Procedure code 1-01996 billed longer than 30 days requires medical necessity documentation. Cancer diagnoses are excluded from the 30-day limitation.

Procedure code 1-01996 is payable to the following providers:

•Independent CRNA.

•Independent CRNA group.

•DO.

•MD.

•Physician group, DO.

•Physician group, MD.

Intrathecal Morphine Pumps

Treatment of intractable pain with an intrathecal morphine pump is a benefit with prior authorization. However, prior authorization is not required if used for the treatment of intractable cancer pain.

The request for prior authorization must include required information. The use of the Texas Medicaid Prior Authorization Request Form: Intrathecal Baclofen or Morphine Pump Section I form is not mandatory; however, the information requested on both pages of the form is required.

Providers are to mail or fax prior authorization requests to the following address:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
Fax: 1-512-514-4213

Pain management is a benefit of the Texas Medicaid Program. Prior authorization is required for procedure codes 2-62350, 2-62360, 2-62361, and 2-62362 unless used for the treatment of intractable cancer pain.

Procedure codes 2-62350, 2-62351, 2-62355, 2-62360, 2-62361, 2-62362, and 2-62365 billed on the same day as another surgical procedure performed by the same physician are paid according to multiple surgery guidelines.

Procedure codes 2-62350, 2-62351, 2-62355, 2-62360, 2-62361, 2-62362, and 2-62365 billed on the same day as an anesthesia procedure performed by the same physician are denied as included in the total anesthesia time.

Reimbursement to the physician for the surgical procedure is based on the assigned RVUs or maximum fee. Outpatient facilities are reimbursed at their reimbursement rate. Inpatient facilities are reimbursed under the assigned diagnosis-related group (DRG). No separate payment for the intrathecal pump is made.

Use the following codes when billing for the implantation/revision/replacement of the pump/catheter:

Procedure codes 1-62367 and 1-62368 do not require prior authorization and are payable as a medical service (TOS 1) only.

Refer to: "Chemotherapy" for more information about implanted pumps.

"Texas Medicaid Prior Authorization Request Form: Intrathecal Baclofen or Morphine Pump Sections I and II (2 Pages)"