Coding and Billing Issues in Pain Management
Principles:
1. Coding should not be delegated to billing companies, secretaries or office staff, or to
certified coders unless there is a mechanism of checks on such activities. The physician is
legally responsible for correct billing and coding of all claims to insurance companies and
social welfare programs such as Medicare and Medicaid. Errors in billing/coding made by
those in the employ of the physician or who are contracted to the physician to provide
billing/coding services do not detract from the personal culpability of the physician for such
errors.
2. Coding and billing are constantly changing and evolving. Therefore a certified coder
should be involved in processing your claims. Sometimes there are no exact codes for a
procedure therefore a professional billing agent experienced in pain management can help
you select the proper code.
3. When starting a practice, do not attempt to have your office do your billing. This often
results in disasterous consequences as billing requires both years of experience in addition to
being current with all the latest coding edits and billing process changes.
4. A correct coding process is part of the HIPPA compliance program for each practice. This
program is mandatory.
5. Make sure you turn in all bills to the staff. It is estimated up to $40,000 per year per
physician is lost in charges not made or not appropriately collected (eg. denied procedure
with no tracking mechanism to maintain pressure on the insurers to pay).
6. Everyone must be charged the same for the same service. A physician cannot give "free
services" to patients as this violates CMS regulations on improper billing and coding. It is
possible and legitimate to write off some or all of the charges after the bill has been received
by the patient. Insurance contracts automatically write off substantial amounts after the
usual fee has been billed.
7. Re-evaluate your physician's fees each year in light of Medicare and other carriers
reimbursement. Typically, charges will be 2-3 times that of Medicare reimbursement to
assure sufficient charges are made to capture sufficient income from discounter insurance
companies that take a percentage off your usual and customary fees.
CODING
The codes used in all submitted bills for services in the US are designed by an uneasy alliance
between public and private sectors. CPT codes are the property of the AMA which is the
private organization giving designation to all therapy codes in the US. CMS (Medicare) has a
contract with the AMA that has existed since 1983 that gives the AMA the exclusive right to
develop CPT codes and the CMS agrees to use only those codes. In return, the AMA derives
nearly 2/3 of their yearly income selling CPT coding books and the rights to use such
proprietary codes (source: American College of Physician's and Surgeons). The AMA uses sub-
specialty organizations/consultants/task forces to make the determination of appropriate
codes and to designate new codes while discarding old codes. NASS has traditionally been
the driving force behind pain management codes even though NASS is heavily dominated by
surgeons and there is little representation of pain management in the board of NASS and in
the membership of NASS. Fortunately, ASIPP, a highly political organization and ISIS, an
almost apolitical organization both have recently had input into coding. The American
Academy of Pain Medicine also has had a voice in developing codes, but has traditionally very
little emphasis on interventional pain medicine. The CPT codes are a 5 digit code with an
optional two digit modifier used to determine in a standardized fashion, what intervention or
interaction the physician had with the patient. CPT codes are updated by the AMA at least
yearly, and sometimes more often. There are no $$ values assigned to CPT codes by the
AMA. CPT codes may require years of debate in order to institute new codes or changes in
codes, however the activities of ASIPP have shortened that time considerably. The
development of new CPT codes do not necessarily mean a procedure or the code for a
procedure are accepted by insurance companies or governmental welfare programs, nor do
they imply payment for a procedure with an assigned CPT code is to be forthcoming. Each
procedure/service is evaluated by the carriers independently of the AMA CPT code, however
most procedures without CPT codes are considered experimental by the insurers/welfare
programs resulting in non-payment. Even when there is a CPT code, Medicare may deem a
procedure to be a covered service while insurance companies may consider the identical code
and procedure to be experimental. One must be constantly on guard for sales
representatives who tout coding errors that may be fraudulent. For instance, disctrode is
exclusively a 62287 (percutaneous discectomy) code, but the sales reps continually are
telling me other physicians in their region are coding the procedure as a 63056 (trans-
pedicular decompression of the spinal cord= through the pedicles). Clearly there is no
placement of a needle or disc dekompressor through the pedicles.
CPT codes are usually bundled. That is, multiple codes are often rolled into a single code
where possible. An epidural blood patch cannot be billed as venous access, epidurogram,
epidural injection all together. There is a single code rather than 3 that cover this
procedure. And so many other procedures are also bundled. There are also mutually
exclusive codes in that one code may be covered, but another code for a similar or other
procedure cannot be billed during the same visit. Click here to see a matrix of mutually
exclusive codes. Other CPT codes may be associated with global 90 or 120 day rules in which
a repeat procedure or similar procedure may not be reimbursed if performed within this time-
frame. Medicare has created a nearly impossible situation with respect to coding, having
taken a simple system and turned it into such contorted complex rules that it is very difficult
to know what code to use in many circumstances. Insurance companies generally have rules
that govern the conditions under which a procedure may be covered but do not resort to the
insane coding rules of Medicare.
There are many modifiers that are available and are attached to each code as a dash with the
two digit modifier attached. Medicare does not pay for some modifiers such as the bilateral
modifier, therefore a physician must either do a procedure on the second side for free or
bring the patient back for a second visit to address the pathology with treatment Medicare
will not pay for on a single visit. Modifiers may be viewed here.
Because coding can be interpreted in many ways, there exists a group that determines for
Medicare proper coding through the National "Correct Coding Initiative" or CCI. Medicare
incorporates the revisions of the CCI into their coding interpretations quarterly. The CCI may
be accessed on line here, however the manual may be ordered from NTIS, an outside
corporation (published each October) on the above website FAQ. But remember Medicare is
a collection of fifedoms in which national policy on coding and billing can be completely
disregarded by the individual intermediaries. The CCI effectively has the effect of "bundling"
multiple codes into one, excluding certain code pairs, and providing an almost limitless
amount of complexity to the coding process.
Pain management codes generally fall into E&M codes, procedure codes, radiological codes,
and J-codes (intrathecal medications and Synvisc injections). There are other codes such as
A codes, S codes, and HCSPCS codes that are not relevant in a pain medicine office practice.
E&M CODES For those blessed with a PM&R or Neurology background, these codes are not
quite so mysterious. Basically, E&M codes are for evaluation and management, ie office visits
and hospital admission/followup visit/discharges. The rules for E&M are so convoluted and
confusing computer programs are available to decipher the scores of documentation
requirements needed to bill these codes. The CMS document describing the 1997 codes
under which we still operate is over 50 pages long and may be viewed here for the
masochistic. Generally the codes are divided into broad categories each with 5 levels of
coding depending on the elements included in the history and physical exam, etc. These 5
levels end in 1-5 based on increasing complexity of the encounter. The basic categories used
in pain management are inpatient (new), inpatient (consultation), new clinic/office patients
(CPT codes 99201-99205), clinic/office (consultation), clinic/office (CPT codes 99211-
99215), each with the 5 levels of complexity as stated above. Each of the 5 CPT codes for
each basic categories has specific requirements regarding the 3 key components and 4
remaining components of the exam.
The three “key components” are: History, Examination, & Medical Decision Making
The remaining components are: Counseling, Coordination of Care, Nature of Problems, Time
A CPT code for E/M service is usually based on the level of complexity of the key components.
New patient or initial services require that all three key components meet or exceed the
published descriptors. Established patient or subsequent services require that two of the
three key components meet or exceed the published descriptors.
There are four levels of complexity in each key component.
The levels for the history and examination key components are: Problem-focused,
Expanded problem-focused, Detailed, Comprehensive
The descriptive levels for the Medical decision making key component are:
Straightforward,Low complexity, Moderate complexity, High complexity
History levels are determined as follows:
Problem-focused includes chief complaint, brief HPI, no ROS, no PFSH
Problem-focused expanded history includes the above + a problem pertinent ROS
Detailed history: CC, Extended HPI & ROS, Pertinent PFSH
Comprehensive history: CC, Extended HPI, Complete ROS and PFSH
HPI has the following 8 elements: Location, Quality, Severity, Duration, Timing, Context,
Modifying factors, and Associated sign and symptoms. A brief HPI contains 1-3 elements.
An extended HPI contains 4 or more elements.
ROS has the following 14 elements: Constitutional symptoms (e.g. fever, weight loss), Eyes,
{Ears, nose, mouth, throat}, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary,
Musculoskeletal, Integumentary (skin and/or breast), Neurological, Psychiatric,
Endocrine, Hemotologic/lymphatic, Allergic/immunologic. The problem pertinent level
has inquires about the system directly related to the problem(s) identified. The extended
level has inquires about he system directly related to the problem(s) identified and a
limited number of additional systems. Two to nine systems should be documented. The
complete level has inquires about the system(s) directly related to the problems(s)
identified PLUS all additional body systems. At least 10 systems must be documented.
PFSH (past medical history, family history, social history) has the following 3 elements:
1. Past history is the patient’s past experiences with illnesses, operations, injuries and
treatments. 2. Family history is a review of medical events in the patient’s family,
including diseases, which may be hereditary; or place the patient at risk.
3. Social history is the review of past and current activities.
There are two levels of PFSH: For pertinent, at least one item from the three areas must be
documented. For complete, 2 or all 3 of the three areas must be documented depending on
the category of E/M.
Examination key component also has 4 levels:
Problem focused – a limited examination of the affected body area or organ system
Expanded problem focused – a limited examination of the affected body area or
organ system and other symptomatic or related organ system(s)
Detailed – an extended examination of the affected body area(s) and other
symptomatic or related organ system(s)
Comprehensive – a general multi-system examination or complete examintion of a
single organ system
The following are the recognized body areas: Head, including the face, Neck, Chest,
including breasts and axillae, Abdomen, Genitalia, groin, buttocks, Back, including spine
each extremity.
The following are the Organ Systems: constitutional (e.g., vital signs, general
appearance), Eyes, Ears, nose, mouth and throat, Cardiovascular, Respiratory,
Gastrointestinal, Genitourinary, Musculoskeletal, Skin, Neurologic, Psychiatric,
Hematologic/lymphatic/immunologic.
The extent of the examination performed and documented is dependent upon clinical
judgment and the nature of the presenting problem(s). Specific abnormal relevant
negative findings of the examination of the affected or symptomatic body area(s) or organ
system(s) should be documented. A notation of “abnormal” without elaboration is
insufficient. Any abnormal or unexpected findings of unaffected or asymptomatic body
area(s) or organ system(s) should be described. If an organ system(s) or body area(s) are
negative or normal, to document “negative” or “normal” is sufficient.
The medical record should include 8 of the 12 organ systems for a general multi-system
examination.
Medical Decision Making Key Component has 4 levels possible:
Straightforward, Low Complexity, Moderate Complexity, High Complexity
[Note: It appears at this point in coding development, the CPT developers completely lost contact with
reality and ventured into a fantasy world of endlessly available physician time to learn their absurd rules.
The world would have been a better place had they all died in an airplane crash en route to their
celebration of this infamous achievement.]
While the actual CMS guidelines drone on and on for many pages on how to asses risk,
complexity, etc, in fact this aspect of the guidelines would require a computer model to
calculate their insane formulas and matrices. Only the first guideline is comprehensible and
only in a general manner: A. Number of diagnosis or management options, B. level of risk to
the patient from the decision, and C. Amount and complexity of the data. Generally these
are ranked minimal, low, moderate, high or extensive. The medical decisionmaking is
straightforward for 3 minimal elements, low complex for 3 low elements, moderate complex
for 3 moderate elements, and high complexity for 3 high/extensive elements.
The integrated coding matrix may be viewed here . Consultation is another physician referring a
patient for an opinion and therefore codes 99241-5 are employed. If a patient refers them
self to your practice, this would be a new patient and codes 99201-5 would be used. A -25
modifier is used if the patient has a procedure on the same day as the E/M code.
It is important to have an OIG approved compliance plan in place for both coding and
billing. If you do internal coding within your office but have an external billing
company, then you should have a coding compliance plan. In that case, your billing
company should have a billing compliance plan. If you have a paper billing system
in-house, then you will definitely need both of these plans implemented. For
practices that rely heavily on an external biller for services, then the biller should
have both compliance plans in effect.
Procedure Codes:
Typically most procedure codes used in pain management are bundled, ie. whereas
multiple codes in the past were used to identify the components of a procedure, now
there are rules to protect against this "unbundling". For instance an interlaminar ESI
cannot be charged as a venopuncture, myelography, catheter advancement, etc. in
addition to the epidural injection code.
Certain procedure codes may also be exclusionary to other codes. In pain
management, this occurs when a physician attempts to bill for multiple pain
procedures simultaneously such as an interlaminar ESI for spinal stenosis along with
an isolated nerve root compression due to a HNP.
In general, coding must be performed either as a very close fit to the code or if there
is not a close fit, as an undefined code ending in 999. The procedures APLD, LASE,
nucleoplasty, disc dekompressor, Perc Scope decompression, etc. are all coded
62287...no other codes apply. Some of the marketers of devices will tell physicians
that other physicians are coding the above procedures as 63056 which is technically
fraud. Do not listen to the equipment or device manufacturers regarding appropriate
coding as their sales reps may mislead you into committing fraud. Another example
is the procedure "pulsed radiofrequency for pain management". Because the pain
management equipment manufacturers have bought the argument that such low
temperatures should be used that it causes no injury to the nerve, correct coding of
any use of pulsed RF at low temperature used for pain management cannot by
definition be coded as the usual neurodestructive code used for RFTC. It is not a
reduced service as would be appropriate with a 52 modifier, but is actually a
fundamentally different procedure resulting in no neurodestruction at all. Therefore
the only appropriate code is 64999. See the coding list on the main page of this
website for more specifics on coding.
BILLING
There are now several avenues to billing including multidisciplinary billing services
(eg. anesthesiology billing service also billing for pain management), single specialty
billing agencies, in-house computer generated billing, etc. If you are starting a
practice and have not yet implemented an electronics medical record system, then
you should seriously consider an integrated EMR/Scheduler/Billing system. But this
requires knowledgable staff in billing and coding plus having the infrastructure set up
to transmit the bills electronically. Most start up offices will not have these
capabilities, therefore a manual system of encoding which is then transmitted to the
billing company is most appropriate.
IF THE BILLING COMPANY SELECTED IS NOT ALREADY DOING PAIN MANAGEMENT
BILLING FOR AT LEAST 2 OTHER PHYSICIAN GROUPS AND IS NOT BILLING AN OFFICE
PRACTICE BUT ONLY INJECTIONS, YOU SHOULD SEEK ANOTHER SOURCE AS A BILLING
COMPANY. The learning curve is very steep for billing companies and typically when they begin to
do pain management billing, they quickly learn it is much more difficult and time consuming
compared to anesthesiology OR billing. With insufficient staff allocated for your accounts, the
accounts receivable will quickly balloon.
Tips in selecting a billing company:
1. Experience specifically with an office based pain management practice
2. Has a complete compliance program
3. Good reporting mechanism with legible easy to read monthly reports
4. On-line capabilities so your staff will be able to check the patient balances and payment histories
with a few keystrokes on your computer when the patients are seen in your practice on return visits. .
5. Make sure claims are filed electronically
6. Do not permit insurers to make deposits into the bank account of the billing company- they can
hold you hostage if you become dissatisfied with their company.
7. Ask for references
8. Make sure the billing company is familiar with the insurers in your state
9. The faster you submit your bills to the insurance company, the more rapid the return...
electronically transmit these daily when possible
10. Ask about the process of collection of monies owed after insurance has paid their contracted
amount. If there is one letter sent out only, then the file is turned over to collections (a very
expensive service costing up to 35% of the amount collected), then you should look elsewhere.
Letters should be sent out every 4 weeks and telephone calls to the patient should be mandatory.
11. Claim denial rates should be less than 5%.
12. Turnover time for claims should be 30-45 days max. With electronic claims submission,
turnover times may be significantly less.
13. Look for hidden fees: if the billing company requires your staff to post EOBs to the account,
personally make deposits to the bank and create a separate list of deposits for the billing company,
etc. then the billing company is using your staff time for their work.
14. A reasonable cost for a billing company is 5-8% of collections. Anything more is excessive.
your billing company: