American Academy of Pain Medicine estimates that over 100 million people suffer from acute or chronic pain, which equates to 20.4% or 1 in 5 adults. This number is far more than the number of patients affected by heart disease, diabetes, and cancer combined. While there’s such growth in pain management care, some of the pain management billing and coding challenges make it difficult to thrive. New state and federal regulations have brought about some unique challenges to pain management billing. Recently pain management is facing billing issues like expanding prior authorization requirements, downward adjustments to fee schedules and shifting financial responsibility to the patient. Once you acknowledge and understand these challenges, there are strategies to improve your pain management collection.
Pain Management Documentation (PMD)
Medical documentation ensures the medical necessity of any procedure. Similarly, pain management documentation (PMD) is a critical element of pain management care. It’s a way to communicate about patients’ problems, treatments, and responses among members of the healthcare team. Complete and accurate pain management documentation will avoid claim denials due to missing or incomplete information. You have to document properly about laterality or which nerves were treated. In the documentation, the provider should include thorough and accurate treatment information which can be included in an operative note of the addendum. Proper documentation allows the medical coding team to chose accurate codes and they can use correct modifiers whenever necessary. Medical coders can code better if they refer to complete documentation and not only a summary.
Payer Policies and Guidelines
Every payer has its own set of billing policies and guidelines. Most of the commercial payers generally follow Medicare guidelines but still, every payer customizes their own billing guidelines. We have witnessed major changes in payer policies and guidelines during the corona pandemic and public emergency. Every payer has responded differently in this time. A good example has been the telehealth changes that impacted patient E/M codes and ICD-10-CM codes during this pandemic. Staying on top of payer policies and billing guidelines will result in lesser denials and quicker insurance reimbursements. In case of confusion, picking up your phone and calling insurance could provide better clarity and might avoid delayed payments. Insurance companies on their websites and provider portals constantly share updated billing guidelines and policies. Training your coding and billing team on these updates is a great way to stay on top of payer policies and guidelines.
Most of the pain management practices often make the mistake of billing fluoroscopy separately. Fluoroscopy is actually included in many pain management codes including discography, intraarticular joint or medial branch block facet joint procedures, transforaminal epidural steroid injections, and radiofrequency ablations. Be sure to understand if this is a bundled charge for the procedure used, i.e., SI joint (27096), medial branch blocks, and facet injections, or is it recognized separately, i.e., fluoro guidance codes for peripheral joints. When you bill fluoroscopy separately, your claims will get denied as a duplicate claim.
Modifiers help to clarify the procedure in detail and the use of the wrong modifier could result in claim denials. Commonly used modifiers in pain management are as follows:
- -LT: anatomically left-RT, anatomically right
- -50: bilateral
- -59: notes that a service or procedure is independent and separate from other services that were performed on that same day
- -52: incomplete procedure, stopping part of the procedure due to reasons other than patient well-being
- -53: incomplete procedure, the physician chooses to end a procedure for the patient’s well-being
When you code for bilateral procedures, you have to use modifier -50. Modifier -50 specifically represents a procedure or service that’s performed on both sides of the patient’s body during one session. Unfortunately, it’s a common mistake to forget modifier -50 or merely code each side of the body separately.
Critical to the success of any pain management coding and billing program is avoiding anything that might trigger a post-service prepayment coding review from insurance payers. Insurance-mandated coding reviews can add up to 180 days (or six months) to receiving payment. There is a solution to face these billing challenges by outsourcing your billing and coding functions to an expert medical billing company like MedicalBillersandCoders. We ensure that proper codes are used to maximize per code collection and reduce denials to keep revenue flowing for your pain management practice. Contact us today and find out how we can help you grow your practice and improve revenue with our services.