Compared to other medical specialties, pain management practices face certain unique challenges related to increased state and federal regulations. This has brought about changes in coding and payer reimbursement policies, increasing the relevance of efficient pain management medical billing and coding services. Here are some of the reimbursement issues that providers have to contend with and tips to help pain management practices improve revenue.
According to a report in Beckers ASC Review, ICD-10 has made it difficult for physicians to meet the demands of payers and federal regulators for pain management procedures. There are many issues involved:
- Payers require physicians to get prior authorization before providing treatment. A procedure will be approved only if there is evidence of medical necessity and if other conservative treatments have failed. Comprehensive medical documentation has to be submitted to prove medical necessity.
- Physicians are constrained by payer rules on how many times they can perform a procedure.
- Practices may have to undergo post-service prepayment coding reviews. Payments may be held up for as long as 180 days when claims are flagged for review.
- To reduce their costs, payers are limiting the type of procedure that can be performed in surgical centers and shifting some procedures to practices.
- There are more controls on prescribing combinations of drugs and complex drugs. Physicians need to prove that the treatment was needed and is a proven pain management procedure is suitable for that particular patient.
- While the CDC and new guidelines from the American College of Physicians recommend the use of alternative non-pharmacologic treatments, payers do not reimburse some of these therapies.
- There are stringent policies regulating the use of pain medications and many physicians who prescribe these medications are under scrutiny for overprescribing them without proper clinical management.
All these challenges make it very difficult for pain management practices to grow their business and stay financially relevant. Here are measures that can help:
- Understand payer rules and new codes: In addition to having a thorough understanding of payer rules, pain management physicians need to ensure accurate claim submission using the latest ICD-10 and CPT codes. CPT 2017 introduces new pain management codes and also deletes several codes. There are also several CPT code revisions.
- Understand and manage the costs of procedures performed: Pain management centers should be aware about managing the costs of therapies such as epidurals as well as complex procedures such as radiofrequency ablation (RFA), says the report in Beckers ASC Review. Centers need to be aware of the difference in the costs of performing a procedure in a clinic versus a surgery center. By evaluating the costs of top procedures, they can determine whether the reimbursements justify the costs. This will help them manage their programs from a clinical as well as cost perspective.
- Varied patient population: In addition to catering to Medicare and Medicaid populations, pain management physicians must focus on growing their business by having patients with commercial and workers’ comp insurance. Pain procedures bring in significant revenue and having a wide and varied population base that includes patients in commercial health plans will help physicians stay competitive.
- Ensure accurate and complete documentation: All areas of the operative note should show what occurred in the patient session. Physicians should continually educate themselves about what constitutes a well-documented operative note to avoid payer approval issues. They also need to know how to fit new procedures into the electronic medical record. One issue here is that there may not be a template for every type of service performed.
- Learn how to negotiate contracts better: Once they are aware of the costs of the various therapies they provide, pain doctors can negotiate contracts with payers better. Negotiating a contract requires knowledge of financial analytics as well as a thorough understanding of the market place and the complexities involved in the business of pain management.
In this complex scenario, the best option for pain doctors is to partner with an experienced medical coding company that has expert AAPC-certified medical coders on board. These experts would be knowledgeable about anatomy as well as about how the physician performs the procedure. Besides knowing payers’ expectations, they can help with ensuring accurate documentation as they would know whether the operative note has the right information and also how to assign the correct codes based on the correct information. These companies also provide expert medical billing analysis to help physicians gauge their facility’s financial performance and make improvements.
Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.