Health Evidence Review Commission's Chronic Pain Task Force...Sep 26, 2017 · Health Evidence...

Health Evidence Review

Commission's

Chronic Pain Task Force

September 26, 2017 10:00 AM - 12:00 PM

Clackamas Community College

Wilsonville Training Center, Room 112

29373 SW Town Center Loop E, Wilsonville, Oregon,

97070

Section 1.0

Call to Order

AGENDA Chronic Pain Task Force

September 26, 2017 10 am – 12 pm

Wilsonville Training Center, Room 112 29353 SW Town Center Loop E

Wilsonville, OR 97070 (All agenda items are subject to change and times listed are approximate)

# Time Item Presenter

1 10:00 Call to Order, Introductions Staff

2 10:05 Purpose of Meeting Darren Coffman

3 10:10 Overview of chronic pain on the Prioritized List and the problem to be solved

Ariel Smits

Denise Taray

4 10:30 Group discussion Staff

5 11:45 Next steps Staff

6 11:55 Public Comment

7 12:00 Adjournment Staff

Section 2.0


2020 Biennial Review Chronic Pain Task Force Roster

Name Specialty

Cat Buist pain psychologist

Jim Shames Primary care

David Eisen Exec Director, non-profit community health clinic

Nora Stern Physical Therapist

Amber Rose Dullea Patient representative

David Sibell Pain specialist

Tracy Muday CCO medical director, primary care

Holly Jo Hodges CCO medical director, primary care

Kevin Cuccaro DO Pain specialist

Laura Ocker/Ben Marx Acupuncture

Kim Jones rheumatology

Mitch Hass chiropractor

Andrew Gibler pharmacist

Revised 9/19/2017

TREATMENT OF

PERSISTENT/COMPLEX/CENTRAL PAIN

ON THE PRIORITIZED LIST


September 26, 2017

Developing a common language about pain…

The International Association for the Study of Pain

(IASP) definitions:

Pain – an unpleasant sensory and

emotional experience associated with

actual or potential tissue damage, or

described in terms of such damage.

Central Sensitization – Increased

responsiveness of nociceptive neurons in

the central nervous system to their normal

or subthreshold afferent input.

• Acute: intermittent, recurring, generally thought

to be of limited duration based on healing

response

• Cancer pain: acute, nociceptive and/or

neuropathic

• Chronic non-cancer pain: broad and can have

application to nociception, neuropathic, and

centralized pain; suggests that cancer pain

should be managed differently

• Chronic pain or chronic pain syndrome:

duration of >3 months or beyond healing time;

suggests pain remains static and is not

changeable

• Persistent pain: suggests pain is changeable

• Complex pain: overprotective brain response,

associated with biopsychosocial impacts,

comorbid conditions and presentation

Mechanistic Characterization of PainNociceptive Neuropathic Centralized

Cause Inflammation or damage

Nerve damage or entrapment CNS or systemic problem

Clinical features Pain is well localized, consistent effect of activity on pain

Follows distribution of peripheral nerves (i.e. dermatome or stocking/glove), episodic, lancinating, numbness, tingling

Pain is widespread and accompanied by fatigue, sleep, memory and/or mood difficulties as well as history of previous pain elsewhere in body

Screening tools PainDETECT Body map or FM Survey

Treatment NSAIDs, injections, surgery, ? opioids

Local treatments aimed at nerve (surgery, injections, topical) or CNS-acting drugs

CNS-acting drugs, non-pharmacological therapies

Classic examples OsteoarthritisAutoimmune disordersCancer pain

Diabetic painful neuropathyPost-herpetic neuralgiaSciatica, carpal tunnel syndrome

FibromyalgiaFunctional GI disordersTemporomandibular disorderTension headacheInterstitial cystitis, bladder pain syndrome

As presented by Danial Clauw

The Problem

• Conditions with associated acute pain (trauma, surgeries, etc.) have full

coverage

• Certain types of conditions with chronic pain have full coverage for a variety

of services

– Ex: osteoarthritis, rheumatoid disease, diabetic neuropathy, contractures

• Other conditions with chronic pain/ centralized pain have no coverage or

coverage for inappropriate services

– Ex: fibromyalgia and chronic pain syndrome are “below the line” and get

only primary care visits and medications such as opioids

• Some pain conditions are only covered for diagnostic work up

– Headache, abdominal pain, etc.

The Hoped-For Future

• Develop coverage of evidence-based services for central/complex/persistent

pain

– Treatments, medications

– Other

• Rehab approach

• Chronic care model/ supportive care

• Develop limitations on possibly harmful services for pain or painful conditions

– Reduce expensive invasive procedures with limited benefit

• Prevention of conversion from acute to chronic

A Quick Primer on the Prioritized List

• The “List” is made up of 660 lines (1/1/18 list)

– Contain ICD-10 diagnosis codes paired with CPT procedures codes

• Coverage is determined by condition/ treatment “pairing” and the “funding line” (line 469 as of 1/1/18)

• Guidelines further define specifics of coverage, are tied to specific lines

• Statements of Intent allow general statements of desired coverage

– Ex: palliative care

• The Legislature draws “the line”

– Above the line (ATL): funded services

– Below the line (BTL): unfunded services

• In reality, primary care visits and non-PA’d medications are covered

Quick Primer on the Prioritized List

• Condition/treatment pairs are prioritized based on a scoring formula that looks at

– loss of healthy life

– pain and suffering

– impact on public health

– ability to prevent poor health outcomes

– effectiveness of treatment

– effects on vulnerable populations

– Note: ability to work is not considered

• Diagnostic and ancillary (DME, supportive) services are generally covered

• Dysfunction or manifestations of CNS conditions (inability to perform ADLs, difficulty in

communication or movement, etc.) are covered, even if actual diagnosis causing the

dysfunction is BTL

Challenges with Changing the PL for Pain

• Condition definitions limited to ICD-10

– Most long-term pain condition descriptions do not follow current pain research and theory

• Treatment types limited to CPT

– Can “fine-tune” with a guideline

• Limited to where there is evidence

– Recent reviews finding limited evidence of effectiveness or no evidence of effective treatments:

• Tension headache (ibuprofen is effective)

• Fibromyalgia

• May have unintended consequences

– Prior authorization MAY limit medications based on BTL/ATL status

– Many services available to ATL diagnoses (DME, etc.) might newly pair

Taskforce charge

• Help identify diagnoses/conditions to address

– Only currently BTL conditions?

• Which ones?

– Also address ATL conditions?

• add limitations for certain services

• Help identify effective treatments for complex/central pain

– What works?

• Medications

• Services: CBT, PT, acupuncture, chiropractic, other?

– What does not work?

• Opioids?

• Other?

• Help identify best method for allowing coverage of effective treatments

• Statement of Intent

• New line with limited package of services

• Your ideas!

Possible Solutions: Statement of Intent

• Pros:

– no need to move diagnoses

– do not need to specify/identify all

diagnoses

– can be very specific about

services (number limits, types of

conditions, etc.)

– could implement sooner

(January 2019)

• Cons:

– still have conditions BTL for

claims processing

– may not be recognized by

automated systems

– not as enforceable

Example of Statement of Intent

• Statement of Intent XXX, Treatment of Persistent/Complex/Central Pain

• It is the intent of the Commission that patients with persistent/complex/central pain have

access to evidence based services to improve their functional status, regardless of the

prioritization of the condition. Such services include:

– Patient education

– Cognitive behavioral therapy, limited to [X number] sessions per year

– Physical therapy, limited to [X number] sessions per year and subject to the limitations in

Guideline Note 6, REHABILITATIVE SERVICES

– Primary care office visits

• Patients with persistent/complex/central pain should not be treated with long term opioid

medications. If patients cannot be tapered off such medications, they are eligible for

services for treatment for dependence on opioid medications

Possible Solutions: New line(s) with limited services

and guideline

• Pros:

– easier for claims system

– can be granular with CPT codes

– guideline fine tunes intent

• Cons:

– may allow unintended

consequences (covered

Ancillary services, medications,

etc.)

– could have conditions ATL and

BTL depending on treatment,

which can cause confusion

– Longer time to implementation

(January 2020)

Example of New Line and Guideline

• Line XXX

• Condition: Complex/Persistent/Central Pain

• Diagnoses: TBD

– Do we also leave on BTL lines for other services?

• Treatments: Limited PT/OT/CBT/Acupuncture/interdisciplinary care/exercise programs as

appropriate.

• Guideline XXX attached to this line to specify service limitations

Example of New Line and Guideline

• Guideline note XXX Treatment of Persistent/Complex/Central Pain

• Line XXX (other BTL lines with conditions?)

• Treatment of Persistent/Complex/Central Pain conditions are included on line XXX only for the following services:

– Patient education

– CBT, limited to [X number] sessions per year

– PT/OT, Structured exercise/ activity programs, limited to [X number] sessions per year with referral

– Acupuncture, chiropractic, limited to [X number] sessions per year

– Muscle relaxants, ibuprofen, Tylenol, SSRIs

– Tricyclic compounds, SSRIs, NSRIs, and anticonvulsants

• Treatment with the following are only included on lines [BTL line numbers]

– Opioid medications, gabapentin, etc.

Possible Solutions: Your ideas!

• Pros:

– you are the experts!

• Cons:

– need assistance from staff to

“translate” into PL

– may not be achievable in the

current system

Discussion

• Determine scope of diagnoses for taskforce

– Just BTL conditions?

• Which ones? What are the highest yield/will make the most impact?

– Include ATL conditions?

– What about acute pain, dental pain, other types?

• Determine direction of research plan for treatments

– What works?

– What does not work?

– Direct staff to literature, resources

• Determine best route for addressing problem

– SOI? New line? Other?

– Staff will mock up for next meeting

Getting in Touch

• [email protected]

• Ariel Smits

– [email protected]

– (503) 528-6538

• Cat Livingston


– (503) 689-3204

• Denise Taray


– 503-373-1605

• Darren Coffman


– 503-373-1616

mailto:[email protected]





ICD-10 Codes

Code Code Description Line List Placement

B02.23_ Postherpetic polyneuropathy 155 155 Herpes zoster; herpes simplex and

with neurological and...

Various E

codes

Diabetes mellitus with diabetic neuropathy several covered lines

F4541 Pain disorder exclusively related to psychological

factors

549 549 Somatic symptoms and related

disorders

F4542 Pain disorder with related psychological factors 401,549 401 Conditions of the back and spine

549 Somatic symptoms and related

disorders

G130 Paraneoplastic neuromyopathy and neuropathy 507 507 Peripheral nerve disorders

G43 Migraine 409 409 Migraine headaches

G4401 Cluster headaches 409 409 Migraine headaches

G44.03 Episodic paroxysmal hemicrania 409 409 Migraine headaches

G4405 Short lasting unilateral neuralgiform headache 409 409 Migraine headaches

G4409 Other trigeminal autonomic cephalgias (TAC 409 409 Migraine headaches

G441 Vascular headache, not elsewhere classified 409 409 Migraine headaches

G442 Tension-type headache and similar conditions 538 538 Tension headaches

G501 Atypical facial pain 440 440 Trigeminal and other nerve

disorders

G546 Phantom limb syndrome with pain 507,534 507 Peripheral nerve disorders

534 Peripheral nerve disorders

G547 Phantom limb syndrome without pain 507,534 507 Peripheral nerve disorders

534 Peripheral nerve disorders

G564 Causalgia 507 507 Peripheral nerve disorders

Various

G codes

Mononeuropathies 507 507 Peripheral nerve disorders

G890 Central pain syndrome 317 317 Stroke

G8911 Acute pain due to trauma Diagnostic

Workup File

(DWF)

Diagnostic procedures

G8912 Acute post-thoracotomy pain 285 285 Complications of a procedure

always requiring treatment

G8918 Other acute postprocedural pain 285 285 Complications of a procedure


G8921 Chronic pain due to trauma 528 528 Fibromyalgia, chronic fatigue

syndrome, and related disor...

G8922 Chronic post-thoracotomy pain 422 422 Complications of a procedure

usually requiring treatment

G8928 Other chronic postprocedural pain 528 528 Fibromyalgia, chronic fatigue


G8929 Other chronic pain 528 528 Fibromyalgia, chronic fatigue


1

ICD-10 Codes


G893 Neoplasm related pain (acute) (chronic) 93,112,113,115,1

26,129,133,135,1

57,158,191,200,2

01,209,211,215,2

16,230,235,238,2

39,259,260,262,2

63,271,276,286,2

87,294,314,315,3

16,329,342,372,3

96,397,418,433,5

93,112,113,115,126,129,133,135,157,1

58,191,200,201,209,211,215,216,230,2

35,238,239,259,260,262,263,271,276,2

86,287,294,314,315,316,329,342,372,3

96,397,418,433,556

G894 Chronic pain syndrome 528 528 Fibromyalgia, chronic fatigue


G9050 Complex regional pain syndrome I, unspecified 292,377 292 Neurological dysfunction in

posture and movement caused b...

377 Dysfunction resulting in loss of

ability to maximize leve...

G90511 Complex regional pain syndrome I of right upper limb 292,377 292 Neurological dysfunction in




G90512 Complex regional pain syndrome I of left upper limb 292,377 292 Neurological dysfunction in




G90513 Complex regional pain syndrome I of upper limb,

bilateral

292,377 292 Neurological dysfunction in




G90519 Complex regional pain syndrome I of unspecified

upper limb





G90521 Complex regional pain syndrome I of right lower limb 292,377 292 Neurological dysfunction in




G90522 Complex regional pain syndrome I of left lower limb 292,377 292 Neurological dysfunction in




G90523 Complex regional pain syndrome I of lower limb,

bilateral





2

ICD-10 Codes


G90529 Complex regional pain syndrome I of unspecified

lower limb





G9059 Complex regional pain syndrome I of other specified

site





H5710 Ocular pain, unspecified eye Diagnostic

Workup File

(DWF)


H5711 Ocular pain, right eye Diagnostic

Workup File

(DWF)


H5712 Ocular pain, left eye Diagnostic

Workup File

(DWF)


H5713 Ocular pain, bilateral Diagnostic

Workup File

(DWF)


I70221 Atherosclerosis of native arteries of extremities with

rest pain, right leg

165,236 165 Preventive foot care in high risk

patients

236 Limb threatening vascular disease,

infections, and vascul...


rest pain, left leg


patients




rest pain, bilateral legs


patients




rest pain, other extremity


patients




rest pain, unspecified extremity


patients



I70321 Atherosclerosis of unspecified type of bypass graft(s)

of the extremities with rest pain, right leg

236 236 Limb threatening vascular disease,



of the extremities with rest pain, left leg




of the extremities with rest pain, bilateral legs



3

ICD-10 Codes



of the extremities with rest pain, other extremity




of the extremities with rest pain, unspecified

extremity



I70421 Atherosclerosis of autologous vein bypass graft(s) of

the extremities with rest pain, right leg




the extremities with rest pain, left leg




the extremities with rest pain, bilateral legs




the extremities with rest pain, other extremity




the extremities with rest pain, unspecified extremity



I70521 Atherosclerosis of nonautologous biological bypass

graft(s) of the extremities with rest pain, right leg




graft(s) of the extremities with rest pain, left leg




graft(s) of the extremities with rest pain, bilateral legs




graft(s) of the extremities with rest pain, other

extremity




graft(s) of the extremities with rest pain, unspecified

extremity



I70621 Atherosclerosis of nonbiological bypass graft(s) of the

extremities with rest pain, right leg




extremities with rest pain, left leg




extremities with rest pain, bilateral legs




extremities with rest pain, other extremity




extremities with rest pain, unspecified extremity



4

ICD-10 Codes


I70721 Atherosclerosis of other type of bypass graft(s) of the

extremities with rest pain, right leg




extremities with rest pain, left leg




extremities with rest pain, bilateral legs




extremities with rest pain, other extremity




extremities with rest pain, unspecified extremity



I83811 Varicose veins of right lower extremity with pain 637 637 Varicose veins of lower extremities

without ulcer or othe...

I83812 Varicose veins of left lower extremity with pain 637 637 Varicose veins of lower extremities


I83813 Varicose veins of bilateral lower extremities with pain 637 637 Varicose veins of lower extremities


I83819 Varicose veins of unspecified lower extremity with

pain

637 637 Varicose veins of lower extremities


M2550 Pain in unspecified joint Diagnostic

Workup File

(DWF)


M25511 Pain in right shoulder Diagnostic

Workup File

(DWF)


M25512 Pain in left shoulder Diagnostic

Workup File

(DWF)


M25519 Pain in unspecified shoulder Diagnostic

Workup File

(DWF)


M25521 Pain in right elbow Diagnostic

Workup File

(DWF)


M25522 Pain in left elbow Diagnostic

Workup File

(DWF)


M25529 Pain in unspecified elbow Diagnostic

Workup File

(DWF)


M25531 Pain in right wrist Diagnostic

Workup File

(DWF)


M25532 Pain in left wrist Diagnostic

Workup File

(DWF)


M25539 Pain in unspecified wrist Diagnostic

Workup File

(DWF)


M25551 Pain in right hip Diagnostic

Workup File

(DWF)


M25552 Pain in left hip Diagnostic

Workup File

(DWF)


5

ICD-10 Codes


M25559 Pain in unspecified hip Diagnostic

Workup File

(DWF)


M25561 Pain in right knee Diagnostic

Workup File

(DWF)


M25562 Pain in left knee Diagnostic

Workup File

(DWF)


M25569 Pain in unspecified knee Diagnostic

Workup File

(DWF)


M25571 Pain in right ankle and joints of right foot Diagnostic

Workup File

(DWF)


M25572 Pain in left ankle and joints of left foot Diagnostic

Workup File

(DWF)


M25579 Pain in unspecified ankle and joints of unspecified foot Diagnostic

Workup File

(DWF)


M545 Low back pain 401 401 Conditions of the back and spine

M546 Pain in thoracic spine 401 401 Conditions of the back and spine

M79601 Pain in right arm Diagnostic

Workup File

(DWF)


M79602 Pain in left arm Diagnostic

Workup File

(DWF)


M79603 Pain in arm, unspecified Diagnostic

Workup File

(DWF)


M79604 Pain in right leg Diagnostic

Workup File

(DWF)


M79605 Pain in left leg Diagnostic

Workup File

(DWF)


M79606 Pain in leg, unspecified Diagnostic

Workup File

(DWF)


M79609 Pain in unspecified limb Diagnostic

Workup File

(DWF)


M79621 Pain in right upper arm Diagnostic

Workup File

(DWF)


M79622 Pain in left upper arm Diagnostic

Workup File

(DWF)


M79629 Pain in unspecified upper arm Diagnostic

Workup File

(DWF)


M79631 Pain in right forearm Diagnostic

Workup File

(DWF)


M79632 Pain in left forearm Diagnostic

Workup File

(DWF)


M79639 Pain in unspecified forearm Diagnostic

Workup File

(DWF)


6

ICD-10 Codes


M79641 Pain in right hand Diagnostic

Workup File

(DWF)


M79642 Pain in left hand Diagnostic

Workup File

(DWF)


M79643 Pain in unspecified hand Diagnostic

Workup File

(DWF)


M79644 Pain in right finger(s) Diagnostic

Workup File

(DWF)


M79645 Pain in left finger(s) Diagnostic

Workup File

(DWF)


M79646 Pain in unspecified finger(s) Diagnostic

Workup File

(DWF)


M79651 Pain in right thigh Diagnostic

Workup File

(DWF)


M79652 Pain in left thigh Diagnostic

Workup File

(DWF)


M79659 Pain in unspecified thigh Diagnostic

Workup File

(DWF)


M79661 Pain in right lower leg Diagnostic

Workup File

(DWF)


M79662 Pain in left lower leg Diagnostic

Workup File

(DWF)


M79669 Pain in unspecified lower leg Diagnostic

Workup File

(DWF)


M79671 Pain in right foot Diagnostic

Workup File

(DWF)


M79672 Pain in left foot Diagnostic

Workup File

(DWF)


M79673 Pain in unspecified foot Diagnostic

Workup File

(DWF)


M79674 Pain in right toe(s) Diagnostic

Workup File

(DWF)


M79675 Pain in left toe(s) Diagnostic

Workup File

(DWF)


M79676 Pain in unspecified toe(s) Diagnostic

Workup File

(DWF)


M79.7 Fibromyalgia 528 528 Fibromyalgia, chronic fatigue

syndrome, and related disorders

N5312 Painful ejaculation 521 521 Sexual dysfunction

R070 Pain in throat Diagnostic

Workup File

(DWF)


R071 Chest pain on breathing Diagnostic

Workup File

(DWF)


7

ICD-10 Codes


R072 Precordial pain Diagnostic

Workup File

(DWF)


R0782 Intercostal pain Diagnostic

Workup File

(DWF)


R0789 Other chest pain Diagnostic

Workup File

(DWF)


R079 Chest pain, unspecified Diagnostic

Workup File

(DWF)


R1010 Upper abdominal pain, unspecified Diagnostic

Workup File

(DWF)


R1011 Right upper quadrant pain Diagnostic

Workup File

(DWF)


R1012 Left upper quadrant pain Diagnostic

Workup File

(DWF)


R1013 Epigastric pain Diagnostic

Workup File

(DWF)


R102 Pelvic and perineal pain 529 529 Chronic pelvic inflammatory

disease, pelvic pain syndrome...

R1030 Lower abdominal pain, unspecified Diagnostic

Workup File

(DWF)


R1031 Right lower quadrant pain Diagnostic

Workup File

(DWF)


R1032 Left lower quadrant pain Diagnostic

Workup File

(DWF)


R1033 Periumbilical pain Diagnostic

Workup File

(DWF)


R1084 Generalized abdominal pain Diagnostic

Workup File

(DWF)


R109 Unspecified abdominal pain Diagnostic

Workup File

(DWF)


R141 Gas pain Diagnostic

Workup File

(DWF)


R309 Painful micturition, unspecified Diagnostic

Workup File

(DWF)


R51 Headache 538 538 Tension headaches

R52 Pain, unspecified Diagnostic

Workup File

(DWF)


R6884 Jaw pain Diagnostic

Workup File

(DWF)


T82847A Pain due to cardiac prosthetic devices, implants and

grafts, initial encounter

285 285 Complications of a procedure


T82847D Pain due to cardiac prosthetic devices, implants and

grafts, subsequent encounter



8

ICD-10 Codes


T82848A Pain due to vascular prosthetic devices, implants and

grafts, initial encounter



T82848D Pain due to vascular prosthetic devices, implants and

grafts, subsequent encounter



T8384xA Pain due to genitourinary prosthetic devices, implants

and grafts, initial encounter



T8384xD Pain due to genitourinary prosthetic devices, implants

and grafts, subsequent encounter



T8484xA Pain due to internal orthopedic prosthetic devices,

implants and grafts, initial encounter



T8484xD Pain due to internal orthopedic prosthetic devices,

implants and grafts, subsequent encounter



M25541 Pain in joints of right hand Diagnostic

Workup File

(DWF)M25542 Pain in joints of left hand Diagnostic

Workup File

(DWF)M25549 Pain in joints of unspecified hand Diagnostic

Workup File

(DWF)N50811 Right testicular pain Diagnostic

Workup File

(DWF)N50812 Left testicular pain Diagnostic

Workup File

(DWF)N50819 Testicular pain, unspecified Diagnostic

Workup File

(DWF)N5082 Scrotal pain Diagnostic

Workup File

(DWF)R3982 Chronic bladder pain Diagnostic

Workup File

(DWF)T82847S Pain due to cardiac prosthetic devices, implants and

grafts, sequela

Informational

Diagnosis File

T82848S Pain due to vascular prosthetic devices, implants and

grafts, sequela

Informational

Diagnosis File

T8384XS Pain due to genitourinary prosthetic devices, implants

and grafts, sequela

Informational

Diagnosis File

T8484XS Pain due to internal orthopedic prosthetic devices,

implants and grafts, sequela

Informational

Diagnosis File

T85840A Pain due to nervous system prosthetic devices,

implants and grafts, initial encounter

422

T85840D Pain due to nervous system prosthetic devices,

implants and grafts, subsequent encounter

422

T85840S Pain due to nervous system prosthetic devices,

implants and grafts, sequela

Informational

Diagnosis File

9

ICD-10 Codes


T85848A Pain due to other internal prosthetic devices, implants

and grafts, initial encounter

422

T85848D Pain due to other internal prosthetic devices, implants

and grafts, subsequent encounter

422

T85848S Pain due to other internal prosthetic devices, implants

and grafts, sequela

Informational

Diagnosis File

10

Health Evidence Review Commission's Chronic Pain Task Force...Sep 26, 2017 · Health Evidence...

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