Description:
Two types of patient-controlled analgesia are described as follows:

1. Intravenous patient-controlled analgesia (IV-PCA): With IV-PCA, the patient pushes a button and self-administers low doses of intravenous narcotic medication via a pump for the relief of pain. This type of pain control is generally used for postoperative purposes, but can also be used for hospitalized patients with other types of severe pain, as well as in the management of pain due to chronic cancer.

2. Patient-controlled epidural analgesia: With patient-controlled epidural analgesia, an epidural or intrathecal catheter is inserted, and local anesthetics or narcotics are used in conjunction with a pump to deliver small doses of the agent directly to the spinal nerves. Because of the low doses needed to obtain pain relief, side effects such as nausea, sedation and respiratory depression can be minimized. This type of pain control is used extensively in obstetrical procedures and for lower-body postoperative pain. It is also used in the pain management of terminal cancer patients and for chronic intractable pain of non-cancerous origin.

With both methods of pain control, the devices are programmed to limit the hourly dosage and intervals between doses to prevent overdosing.

Policy:
IV-PCA is MEDICALLY NECESSARY in the management of postoperative pain following major surgical procedures and for the medical management of chronic unresponsive cancer pain.

Patient-controlled epidural analgesia is MEDICALLY NECESSARY following obstetrical procedures and major surgical procedures involving the organs of the pelvis and lower extremities; for the medical management of chronic cancer pain; and for chronic intractable pain of non-cancerous origin.

Benefit Application
BlueCard/National Account Issues
For hospitalized patients, intravenous patient-controlled analgesia (IV-PCA) can be an itemized part of the facility reimbursement (e.g., the drug, pump/meter, IV hook-up and associated nursing care). The professional (physician) service is included in the reimbursement for daily medical care visits or is included in the reimbursement for an associated surgical procedure. Physicians should not bill PCA as a separate procedure, nor should the physician bill for concurrent medical care or consultation (e.g., anesthesia and other specialties) when performed for PCA.

For epidural patient-controlled anesthesia, benefits are provided for the initial placement of the epidural catheter as well as for visits by the anesthesiologist to monitor epidural analgesia. If epidural anesthesia is administered for the surgical procedure and the catheter is left in postoperatively for pain management, benefits are provided only for the daily visits, since anesthesia services have already been provided.

Benefits are available for only one inpatient visit per day by the anesthesiologist for up to three days for the postoperative monitoring of patient-controlled epidural analgesia without documentation of medical necessity.

Home Health Care benefits may be provided for pump refill and catheter care if Home Health Care guidelines are met.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved." 

History From 2024 Forward     

01/01/2024 NEW POLICY