Chronic pain is one of the most significant health problems in the United States, costing the nation billions of dollars in lost work time and productivity and reduced quality of life. It is estimated that between 11% and 40% of US adults are living with chronic pain. As pain medicine specialists focus on providing patient-centered and coordinated care, they also have to deal with increased scrutiny from insurance companies, changing codes, expanding prior authorization requirements, cuts in fee schedules, and increase in patient financial responsibility. Partnering with a pain management medical coding company is a practical strategy to optimize revenue cycle management (RCM). In fact, understanding the fundamentals of pain management medical billing and coding is essential to optimize these processes.
Pain Management Billing – Know the Rules
Like all other medical specialties, pain management billing and coding has its own set of challenges. To obtain proper reimbursement for services rendered, practices need to ensure that staff are equipped with the right tools and the necessary information. Here are 8 top tips to optimize pain management medical billing and coding:
- Know the codes and billing guidelines: It’s crucial for practices to stay up to date with CPT code changes. Physicians perform a range of needle procedures and need to be knowledgeable about how to use the relevant codes on claims. Let’s take a look at trigger point injection coding. The following information is from a recent Medicare article:
- Acupuncture is reported with CPT codes 97810 – 97814. Starting January 21, 2020, Medicare covers all types of acupuncture including dry needling for chronic low back pain within specific guidelines in accordance with National Coverage Determination (NCD) 30.3.3.
- There are specific rules for coding trigger point injections and injections of tendon sheath, ligament, ganglion cyst, carpal and tarsal tunnels. Code 20552 is used for injection of one or two muscle groups, and 20553 for three or more muscle groups. Only one of these codes can be billed per session.
- The number of services for either code is one, regardless of the number of injections at any individual site, and the number of sites.
- Other trigger point injection codes include –
20560 and/or 20561, dry needling
20550, Injection(s); tendon sheath, ligament
20551, Tendon origin/insertion
28899 (unilateral procedure, foot or toe)
- Regardless of the number of sites, trigger point injections must be billed on only one line. Multiple injections per day, at the same site, are considered one injection and should be coded with one unit of service (NOS 001).
Likewise, there are many codes for injections of tendon sheath, ligament, ganglion cyst, carpal and tarsal tunnels.
Providers must also use the right ICD-10 codes to indicate diagnoses. There are extensive ICD-10 guidelines on how different types of pain should be reported and the code sequencing process.
CMS has proposed new HCPCS codes and valuation for chronic pain management and treatment services (CPM) for 2023. Another change that will impact pain management practices effective January 1, 2023 is the revised coding and updated guidelines for the category of “Other E/M” visits (www.anesthesiallc.com).
- Ensure proper documentation: Providers must compile all the necessary documentation as errors and missing information will lead to denials. The patient’s medical record must contain documentation that fully supports the medical necessity for services. Include anesthesia records, the operation/procedure report (stating laterality), H & P reports, documents supporting diagnosis codes for the service/item billed such as results of pertinent diagnostic tests or procedures, documentation to support CPT code and modifier billed, documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD), etc. With detailed, accurate documentation, coders can assign the correct codes and modifiers.
- Stay updated on Medicare and private payer guidelines: When submitting medical claims, practices need to get the codes right and also apply the right rules. A major mistake a practice can make is applying Medicare rules to all payers. As Medicare and private payer reporting guidelines vary, practices must be up-to-date. Private payers may have different rules from Medicare for globals, bundling, coverage, and modifier usage. Private payer websites provide payment polices and provider manuals on their website. Coding requirements for Medicare are available on the CMS website in the Medicare Claims Processing Manual, Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
One example where payer rules differ is acupuncture. Medicare covers acupuncture but only for chronic low back pain. CMS defines chronic low back pain as that which:
- Lasts 12 weeks or longer;
- Is nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
- Is not associated with surgery; and
- Is not associated with pregnancy.
When billing acupuncture for chronic low back pain, check payer rules individually, or check the physician payer contract to see if they cover acupuncture for chronic low back pain.
An AAPC article recommends obtaining a signed Advance Beneficiary Notice of Noncoverage (ABN) from Medicare patients scheduled for acupuncture for their chronic back pain. Appending modifier GA Waiver of liability statement issued as required by payer policy, individual case to the acupuncture code(s), as appropriate will indicate an ABN has been obtained.
- Know fluoroscopy billing rules: Fluoroscopy is a part of many radiological supervision and interpretation procedures, including, but not limited, to most spinal, endoscopic, and injection procedures and should not be reported separately. However,
there are separate fluoroscopic guidance codes (77002 for non-spinal) which may be reported separately for peripheral joints/ligaments/bursa (hips, shoulders, iliolumbar ligament, troch bursa, etc. (thepainsource.com).
- Assign modifiers correctly: When reporting services/procedures, providers must use the correct modifiers. Here are some examples of modifies use for Medicare:
- Modifier 50 Bilateral Procedure indicates that bilateral procedures were performed in the same session. Before applying this modifier, the coder should check the CPT code definition to confirm that bilateral is not included in its descriptor. When injecting a sacroiliac joint bilaterally, apply modifier 50.
- Modifier 59 Distinct Procedural Service identifies procedures or services that are not usually reported together. This modifier indicates that a procedure is separate and distinct from another procedure on the same date of service. Modifier 59 may be applied to indicate the following: Different session or encounter on the same date of service; Different procedure distinct from the first procedure; Different anatomic site, and separate incision, excision, injury or body part. Report injection of separate sites (tendon sheath, ligament or ganglion cyst) during the same encounter on a separate line of coding and append modifier 59.
- LT – left side and RT – right side. When injecting a sacroiliac joint unilaterally, use modifier -LT or – RT as appropriate.
Appropriate modifier application depends on the particulars of the claim and the payer’s preference. An article from the California Medical Association notes that, “For Medicare and many commercial payors, proper application of modifier 50 increases reimbursement to 150 percent of the allowable fee schedule payment for the code to which the modifier is appended”.
- Perform insurance verification: Verifying the patient’s insurance coverage and benefits prior to date of service is crucial to avoid denials and receive payment for services. With proper insurance verification services, providers can check whether the patient’s current coverage details, services are covered and deductibles are met before providing treatments.
- Prior authorizations: Physicians must obtain advance approval from a health plan before a specific pain management service is delivered to the patient to qualify for payment coverage. For instance, pain medications and interventional pain procedures require prior authorizations. The process of obtaining these approvals can be a big headache pain medicine physicians and patients and is best done with the right support.
- Ensure that limits on approved procedures are not exceeded: If the number of procedures performed exceeds the limit prescribed, the visit(s) may be disallowed. AAPC references Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pa as saying,” Medicare patients will be limited to no more than 20 acupuncture sessions a year. Treatment must be stopped if the patient shows signs that they are not improving or are regressing.”
The best way to optimize pain management billing and coding is to outsource the tasks to an experienced medical billing and coding service provider. Leading companies are well-equipped with the professional expertise and resources to help pain management practices submit accurate claims and maximize reimbursement.