Postoperative Pain Management

POLICY NUMBER

L.7.02.401

DESCRIPTION

Postoperative pain management is achieved by applying effective methods of analgesic control. Many factors influence the incidence and severity of postoperative pain. Infants and elderly patients seem to experience less pain than middle-aged patients. The need for postoperative pain medication is reduced when the anesthesiologist visits patients preoperatively and provides detailed explanations of postoperative events, including the occurrence of pain. The site of operation influences the severity of postoperative pain, with thoracotomy and upper abdominal and orthopaedic surgery being the most painful. Patients should be seen daily to evaluate the quality of analgesia, side effects, appropriate dosage, and inspection of IV and epidural sites. Several methods of analgesic control are listed below:

Continuous/Intermittent Epidural

The patient is placed in the sitting or lateral decubitus position for the physician to insert a catheter into the vertebral interspace of the cervical or thoracic region for continuous or intermittent infusion of material. The site to be entered is sterilized, local anesthesia is administered and the infusion catheter is inserted. Contrast media with fluoroscopy may be injected to confirm proper placement. The physician provides continuous infusion or intermittent bolus injections of an anesthetic solution. The solution is injected into the epidural or subarachnoid space. With the procedure complete the needle is removed and the wound dressed.

Implantable Infusion Pump

Refer to the  Implantable Infusion Pump medical policy.

Intravenous Patient-Controlled Analgesia (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 managed by the operating surgeon or an anesthesiologist. It can be used for postoperative pain, in hospitalized patients with other types of severe pain and in the management of chronic pain due to cancer. The device is programmed to limit the hourly dosage and intervals between doses to prevent overdosing. IV-PCA should not be confused with pain control infusion pumps.

Pain Control Infusion Pump

Refer to the  Pain Control Infusion Pump medical policy.

Single Injection of Narcotics

The patient is placed in a sitting or lateral decubitus position for the physician to insert a needle into the vertebral interspace of the lumbar or sacral region. The site to be entered is sterilized, local anesthesia administered and the needle is inserted. Contrast media may be injected to confirm proper needle placement under fluoroscopy. The physician injects an anesthetic solution into the epidural or subarachnoid space. With the procedure complete, the needle is removed and the wound is dressed.

POLICY

The management of postoperative pain following surgical procedures is included in the attending physician's evaluation and management services. Charges for these services should not be billed separately.

If the management of postoperative pain is provided by an anesthesiologist, the following guidelines apply:A.  For pain management by continuous/intermittent epidural:

1. Allow payment for 62318 once, on the first day of service. This code includes insertion of the catheter and injection of the anesthetic substance.

2. Allow payment for 01996 for daily management of the epidural drug administration after the day on which the catheter was introduced. Do not allow both 01996 and 62318 on the same day. Documentation supporting medical necessity must be submitted for treatment exceeding 3 days.

B.  Intravenous patient-controlled analgesia (IV-PCA) is included in the global fee for administration of general anesthesia and should not be billed separately.

• For hospitalized patients, most of the cost associated with intravenous patient-controlled analgesia (IV-PCA) is an itemized part of the facility reimbursement (e.g., drug, pump/meter, IV hook-up and associated nursing care).

• The IV-PCA professional (physician/anesthesiologist) services may not be billed separately. This would include the following services:

  1. Initial consultation/visit

  2. Subsequent consultations/visits

  3. Dosing

  4. Calibration/recalibration of the PCA pump

  5. Any other services associated with the management of patient controlled analgesia

C.  A single injection of a narcotic immediately prior to or following the administration of general anesthesia is not included in the global fee for administration of the anesthesia. This injection can be billed separately.

NOTE:

 It is not appropriate for providers to bill the patient for services outlined in B.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

11/1999: Approved by Medical Policy Advisory Committee (MPAC).

1/11/01: Policy "Patient-Controlled Analgesia" renamed "Postoperative Pain Management."

2/2001: Interim Policy approved by MPAC; Existing coverage unchanged. Policy revised to include anesthesiologist management by continuous/intermittent epidural and a single injection of a narcotic following the administration of general anesthesia.

5/2/2002: Type of Service and Place of Service deleted.

11/12/2003: Code Reference section updated, CPT code 01997 deleted.

2/16/06: Section C of POLICY updated to allow for a separate allowance for a single injection of narcotic following the administration of general anesthesia (per BCBSMS Management, effective 8/2004).

12/31/2008: Policy reviewed, no changes.

12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions.

06/03/2010: Policy description and statement unchanged. Coding section updated to move CPT code 62311 from non-covered to covered per the policy statement for the administration of a single injection.

06/11/2014: Policy statement regarding a single injection of a narcotic following the administration of general anesthesia was revised to state that the narcotic injection can be administered immediately prior to or following the administration of general anesthesia.

12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 64486, 64487, 64488, and 64489.

08/14/2015: Code Reference section updated for ICD-10.

12/31/2015: Code Reference section updated to add CPT codes 64463 and 64999.

06/01/2016: Policy number L.7.02.401 added.

12/30/2016: Code Reference section updated to add new 2017 CPT codes 62322, 62323, 62324, and 62325. Removed deleted CPT code 64412.

05/18/2018: Medical policy links updated in policy description. Code Reference section updated to remove deleted CPT codes 62311 and 62318.

12/19/2019: Code Reference section updated to revise code descriptions for CPT codes 64400, 64405, 64408, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, and 64450 effective 01/01/2020.

12/18/2020: Code Reference section updated to revise description for CPT code 64455, effective 01/01/2021.

12/20/2022: Code Reference section updated to revise the description for CPT codes 64415, 64416, 64417, 64445, 64446, 64447, and 64448, effective 01/01/2023. Removed deleted CPT codes 64402, 64410, and 64413.

01/18/2023: Policy reviewed; no changes.

02/14/2024: Policy reviewed; no changes.

03/13/2025: Policy reviewed; no changes.

SOURCE(S)

1. Basics of Anesthesia, 2nd ed. (Robert K. Stoelting, M.D. and Ronald Miller, M.D.), Churchill Livingstone, Inc., New York, Edinburgh, London, Melbourne, Tokyo (1989), pp . 435.

2. Blue Cross Blue Shield Association policy # 10.01.07

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy. 

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes 

Not Medically Necessary Codes 

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