Pain management practices face several unique medical billing challenges. Accurate billing and coding is essential for proper reimbursement and compliance, but can be challenging due to the complexity and specificity of the treatments. Outsourcing pain management medical billing is a practical strategy to optimize revenue cycle management (RCM).
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Common Challenges in Pain Management Billing
Here are some of the coding and billing challenges faced by pain management specialists:
Coding complexity: One of the most common issues relates reporting the wide range of pain management interventions rendered. From injections, nerve blocks, medication, and physical therapy to complex spinal surgeries, each treatment has specific CPT and ICD-10 codes. Accurate coding is essential but challenging.
Higher risk of denials: Another challenge is the higher risk of claim denials. Insurers often scrutinize pain management claims closely. For example, as pb-law.com reports, soft tissue are difficult to measure objectively and prone to scrutiny by payers. Injuries to the soft tissue are often subjective and challenging to diagnose with precision. Symptoms such as pain, swelling, and limited mobility, make these cases particularly vulnerable to fraud, as some individuals may exaggerate their symptoms to obtain compensation. To address this issue, insurance companies have implemented rigorous processes to closely scrutinize soft tissue injury claims, often requiring substantial evidence to prove necessity before approving a claim.
Documentation requirements: Pain management practices must provide extensive documentation to support the medical necessity of treatments. This includes detailed patient histories, treatment plans, and evidence of conservative treatments before more invasive procedures.
Pre-authorization requirements: Insurance companies require prior authorization for many pain management procedures. Obtaining these authorizations can be time-consuming and complicated, particularly for complex or experimental treatments.
Regulatory compliance and guideline updates: Pain management practices must navigate complex regulations including the strict guidelines surrounding opioid prescriptions. For instance, the Centers for Disease Control and Prevention (CDC) has guidelines that recommend limiting opioid prescriptions to the lowest effective dose and for the shortest duration necessary, often no more than a few days for acute pain. Additionally, many states have implemented Prescription Drug Monitoring Programs (PDMPs), requiring physicians to check a patient’s prescription history before prescribing opioids to prevent “doctor shopping” or over-prescribing.
The guidelines for pain management, especially those related to opioid use, are frequently updated. Staying compliant with these changes while ensuring accurate billing is an ongoing challenge.
Patient financial responsibility: High deductibles and co-pays are common in pain management, often reaching thousands of dollars. This places a substantial financial burden on patients, making it difficult for practices to collect payments, especially when patients are already coping with chronic pain.
Implementing robust billing practices is essential to address these challenges and ensure accurate billing and coding.
Top Strategies to Optimize Pain Management Billing
Here are some effective strategies to optimize billing for pain management interventions, prevent denials, and ensure proper reimbursement:
Accurate Coding
Pain management physicians need to ensure accurate claim submission using the latest ICD-10 and CPT codes. Every year, the Centers for Medicare & Medicaid Services (CMS) revise the guidelines for chronic care management. Providers must stay updated on the latest coding changes and billing guidelines to ensure proper reimbursement. For instance, changes in 2024 include the introduction of a new CPT and a new HCPCS code:
- CPT code 27278, Arthrodesis, sacroiliac joint, percutaneous, with image guidance, including placement of intra-articular implant(s) (e.g. bone allograft[s], synthetic device[s]), without placement of transfixing device.
- HCPCS code G2211, an add-on payment for outpatient and office visits applicable when clinicians are the primary focal point for a patient’s care
There are several things to consider when coding pain management procedures like trigger point injection coding:
- Number of injections: Only one code from 20552 or 20553 should be reported per day, regardless of the number of injection sites.
- Drug used: The drug used for the injection must be on the same claim as the trigger point administration.
- Number of sessions: No more than three TPI sessions are considered reasonable and necessary in a 12-month period.
- Medical necessity: Routinely used injections or dry needle injections are not considered medically necessary.
- Medicare, Medicaid, and commercial carriers’ payer polices should be reviewed before performing trigger point injections.
It’s also crucial to know fluoroscopy billing rules. Many pain management procedures involve the use of fluoroscopy, which is sometimes incorrectly billed as a separate service. Knowing whether these procedures should be bundled or billed individually is crucial to avoid claim rejections for duplicate charges.
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.
Proper Documentation
The patient’s medical record should include a detailed procedure note with information about the techniques used, injection sites, drugs, and doses. Errors and missing information will lead to denials. For all pain management treatments, the patient’s medical record must contain documentation that fully supports the medical necessity for services. This includes 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 Payer Guidelines
When submitting medical claims, practices need to get the codes right and also apply the right rules. One 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. 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. 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.
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 modifier 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 may be applied to indicate: 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.
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 eligibility verification, providers can understand the patient’s current coverage details before services are provided.
Prior authorizations
Physicians must obtain advanced 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.”
Outsourcing the billing and coding task to an experienced pain management medical billing company is an effective way to optimize your practice’s RCM. Top-tier companies bring specialized expertise and resources, ensuring accurate claim submissions and helping pain management practices maximize their reimbursements.
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