Incentivizing Bad Medicine

  • Kotecha, Mona, MD
| Apr 28, 2013

Editors Note: The actual language in Noridian’s proposed regulation referenced in this article is as follows:

"Reimbursement for the control or management of pain in the immediate postoperative period is bundled into the payment for the procedure, surgical or anesthetic-regardless of the method by which the care provider, including the anesthesiologist, decides to manage pain. Following discharge from the post-anesthesia care unit (PACU), the medically reasonable and necessary placement of regional or peripheral pain blocks or initiation of other new pain interventions or “top-up” dosing may be reimbursable. Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control."

I have been informed that ASA and anesthesiologists serving on Noridian Carrier Advisory Committees  (CAC) are working with Noridian to have modifications made to the proposed regulation. Substantial progress has been made in assuring that separate payment for these services will be preserved. Noridian will be requiring documentation that is, at a minimum, consistent with the most recent update of the National Correct Coding Initiative (NCCI) on this topic. This requires written advance request from the surgeon to delegate acute pain management care to the anesthesia provider. Noridian has indicated that an order and a note documenting this request will be necessary as will a note from the anesthesia provider accepting responsibility for care. At the CAC meetings, Noridian representatives have indicated a surprising rate of absent documentation for the acute pain procedure itself. Without documentation, payment will not be allowed and recoupment would occur.


In the latest attempt to chip away at payment for anesthesiologists’ services and expertise, Noridian Administrative Services, the Medicare contractor for 10 states, including Oregon, Washington, and Arizona, hopes to bundle payment for interventional post-operative pain management procedures into surgical anesthesia care. The draft policy can be found online here.

What does this policy mean? If passed, anesthesiologists in these states won’t get paid separately for a nerve block or epidural performed pre-operatively for the purpose of post-operative pain management. They will, however, get paid if the procedure is performed to rescue a patient from severe pain.

You read correctly, and it’s worth repeating. The above-referenced document states, “providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control.” This represents a sharp departure from current policy, which pays for interventions that are for the express purpose of post-operative pain control, assuming that the procedure is not intended as a primary anesthetic and that the time performing the procedure is not billed as anesthetic time.

Let’s recap this latest perverse instruction to practice bad medicine by our non-friends working on behalf of CMS, the Centers for Medicare and Medicaid Services. Here’s how I imagine the Noridian algorithm on how to practice peri-operative medicine playing out:

Step one: place your patient under general anesthesia for a known anticipated painful surgical procedure.

Step two: deliver an anesthetic that results in the patient experiencing severe pain.

Step three: discharge your patient from high-level care in the post-anesthesia care unit, where narcotics and other multi-modal pain adjuncts can be administered under close monitoring by specially trained nurses.

Step four: document in the chart that despite the fact that you approved discharge from the PACU, your patient is still in severe pain.

Step five: perform a rescue nerve block, relieving your patient of unnecessary suffering and the unmitigated sympathetic discharge and stress response that results from poorly managed pain.

None of us really intends or wants to practice medicine this way. Should the draft become policy, most providers in those states would probably still soldier on, providing patients with the highest level of care, practicing at the top of their licenses, and, if indicated, performing indicated procedures pre-operatively. That kind of care – the kind that involves administering pre-emptive analgesia, sparing narcotic and volatile agents, attempting to reduce post-operative nausea and vomiting, and even aborting the neuronal wind-up that contributes to the development of chronic pain – is the level of care our patients deserve.

But how much longer can we afford to practice for free? Having special expertise in regional anesthesiology and acute pain, I recognize that nerve blocks and epidurals carry with them both risks and benefits. But for the right patient, they are invaluable adjuncts to peri-operative care that deserved to be compensated fairly, commensurate with the level of expertise required and risks undertaken. America is in the midst of an opioid-dependence epidemic, which makes multi-modal interventional pain approaches all the more important. Pain is considered a “fifth vital sign” and its treatment a social and ethical imperative. Now, providers in these states will simultaneously face the regulatory mandate to treat pain multi-modally and aggressively and the reality that they will not be paid to do so.

Noridian’s latest draft is a symptom of a greater ill in modern health care: the devaluing of physician time and expertise. The policy above, simply put, incentivizes the practice of bad medicine. It undermines the advances our specialty has made in acute pain management. And above all, it has the potential to harm our patients. While California is in a different CMS jurisdiction, the passage of this draft bodes ominously for our own state’s future.

Noridian intends to accept comments on the draft until July of this year. Write to them now at and reach out to your colleagues in those ten states. They can contact their specialty representation on their state’s Carrier Advisory Committee to speak out on behalf of their patients. We can no longer stand idly by and watch the erosion of fair payment for our services and the passing of policies that promote the practice of bad medicine.

Our patients deserve better.

Leave a comment