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Building a Successful Pain Practice

Ruth D. Morton, Ph.D.
Vice President for Administration & Organizational Development Anesthesiologists Associated, Inc. (AAI)

Meet AAI client William Binegar, MD, who practices in the relatively small market of Boise, Idaho. Boise is a small city (pop. 200,000) surrounded by a rural area where a board certified anesthesiologist might not see much potential for building a pain practice. But Binegar possessed the vision, motivation, business acumen, and clinical skills to build what has become a successful pain practice.

Dr. Binegar started practicing in Boise in 1991 after completing his anesthesia residency at the Mayo Clinic in Rochester. As a member of a group providing anesthesia at a local hospital he was given some pain cases that utilized his training in the sub-specialty of Interventional Pain Management. Binegar became board certified in Pain Management in 1994, shortly after the first certification exam was offered. From there, responding to the need in the Boise community, the pain practice gradually grew as he transitioned from the OR into a full pain practice through the hospital’s pain management services.

With a sound business plan that included an emphasis on marketing, Dr. Binegar launched his own practice in early 2004. He bought and rehabilitated a building in the city core with good visibility and in a high traffic location. His RN wife, Wendy Binegar, with sound business and marketing instincts, guided many aspects of the construction, clinic set-up, and marketing. They hit the ground running. While he initially feared that business would be slow and that he would need to tap the line of credit he had arranged, the fear was unwarranted. In four years the business has experienced steady growth. Today, Dr. Binegar enjoys a robust and satisfying practice—Pain Care Boise&,dash;that employs a PA, five medical assistants, a Nursing Administrator, and a Practice Representative at his pain clinic and AAAHC fully accredited ambulatory surgery center in downtown Boise.

Factors Contributing to Growth and Success

When Dr. Binegar started he was among the first in the greater Boise area to provide chronic pain services. But today there is more competition with at least 15 pain practitioners and a pain center at one of the two largest hospitals. Several factors have contributed to the growth and success of Pain Care Boise despite the increasingly competitive environment.

Clinical Expertise and Motivation

Dr. Binegar is board certified in both Anesthesiology and Pain Medicine, and he keeps current with new technology, techniques, and treatments through CME courses. He has gained the confidence of referring physicians, whom he regards as customers in this context, with referrals from well over 200 referring physicians in a year. Among them are orthopedic surgeons, neurosurgeons, neurologists, chiropractors, oncologists and family practitioners. By providing services in both a clinic and an ASC, he has diversified his product line to include:

• Spinal Cord Stimulation
• Radiofrequency Ablation
• Peripheral Nerve Injections
• Discograms
• IntraDiscal ElectroThermal Annuloplasty
• Coblation/Nucleoplasty
• IDD Therapy / Advanced Traction Technology
• Stellate Ganglion Blocks
• Lumbar Sympathetic Blocks
• Epidural Steroid Injections/Interlaminar Technique
• Nerve Root Injection/Tranforaminal Epidural
• Facet Joint Injections



Dr. Binegar uses his skills and has invested in current technology and competent staff to aid him in providing “treatment for improved life.” In part, this tag line of his practice informational material reflects his motivations. He enjoys performing interventions, talking with patients and getting to know them. Helping patients with their pain – having them return and say “You saved me” – is very satisfying. The gratitude of patients is evidenced by several hand-written “thank you” notes posted behind the scenes on the clinic lunch room bulletin board. Beyond the satisfaction of his work, clinic and ASC ownership provides independence from the dynamics of the hospital and surgeon relationships, and supports his own quality of life and family lifestyle with no call or night-time trauma work. And, in turn, he is dedicated to improving the quality of life for all whom he treats.

Patient Focused Care and a Caring Clinic/ASC Environment

Observation of the Clinic and ASC during business hours reveals many examples of intentional patient-focused practices and protocols that Pain Care Boise has developed. Patients are welcomed warmly by front office staff. Wait times are kept to a minimum by appropriate scheduling and efficient work flow design, so patients feel valued and important. Interactions with patients are respectful and friendly without seeming patronizing. Staff members take time to listen to patient stories and field their expressions of angst. Patients are provided with written information about procedures and treatments that help them make informed decisions. The practice web site provides downloadable patient forms that can be completed at the convenience of the patient. When scheduling new patients who have no internet access the office mails a packet complete with information about the practice, financial information, printed forms, a business card, and HIPAA materials.

The clinic and ASC physical environments were carefully designed and decorated to be friendly and comforting as well as safe, efficient, and professional. Dr. Binegar intentionally reinforces the facility design as he purposefully takes his time with patients, and focuses on enjoying what patients bring to him, while also staying on task and on time.

Exceptional Marketing and Communication

Pain Care Boise utilizes a multi-dimensional approach to marketing and branding that others can emulate. First and foremost they have a clear marketing plan. Second, they have one individual in charge of marketing. Their approach to patient care, the patient experience, and “treatment for life” are integral to their branding and the practice identity. All elements of their marketing weave similar messages and themes — whether in their user-friendly web site (“http://www.PainCareBoise.com”), their print informational materials for patients and physicians, or their billboard, newspaper, or radio ads. They utilize patient testimonials excerpted from the patient satisfaction surveys they routinely conduct and from voluntary expressions of gratitude sent to the practice. Testimonials, along with information about Dr. Binegar, are played while telephone callers are placed on hold. Patients recently gave live testimonials for radio spots produced at a local station studio.



Two other elements are key components of their marketing and communication process: 1) a strong tracking and referral program, and 2) a comprehensive internal marketing program.

Referral Program—Essential to launching any new specialty practice is the referral chain. Wendy Binegar initially took on the role of Practice Representative to reach out to potential referring physicians, educate them about services, and ensure that communication is effective in maintaining a referring relationship once established. Care is taken to provide appropriate patient information to referring physicians so they are assured of their patient’s care. When patients come on their own, they are asked the identity of their primary care physician, and if it is permissible to share treatment information with the other physician. If the patient agrees, Dr. Binegar sends a report to the primary care physician as a courtesy. In this process of “reverse referral”, the Practice Representative follows up with a letter and visit to the physician, providing information on all the services provided by Pain Care Boise.

Additionally, referrals often come from satisfied patients. When patients are the source of a referral, Dr. Binegar calls them to thank them for their trust and their referral. Dr. Binegar also annually meets individually with physicians who give him frequent referrals, seeking to learn if he is accomplishing what the referring physicians intend.

Internal Marketing—Office staff are responsible for helping the practice deliver on its brand promise. They reinforce, through their behavior, a caring and competent practice. They also utilize protocols and “scripts” that help them listen to potential patients carefully; ask questions that solicit information relevant to future treatment; provide information about Dr. Binegar, treatments, insurance, and costs, and guide patients and potential patients appropriately.

Excellent Employee Programs



Employees are selected and developed in alignment with the practice goals of high clinical quality and a caring environment. Clinical protocols were developed and documented to guide staff in preparing and assisting in the treatment of patients. Office procedures were also developed and documented and all medical assistants are cross-trained in their roles in both the clinic and ASC, as well as in office positions. An employee manual spells out employment policies, benefits, and expectations. Innovative incentives for efficiency and new patient scheduling, celebrations of marriages, birthdays, and births, and employee social events build staff camaraderie and enhance staff commitment to the practice. The range of excellent employee programs increases the capability of employees, in marketing terms, “to deliver on the brand promise.”

Billing Partner that Supports the Business Goals

Integral to the successful growth of Pain Care Boise has been its relationship with its billing company – Anesthesiologists Associated, Inc. (AAI), which is now the West Coast division of ABC. Based in Oregon, AAI, with a nearly 50 year history of serving anesthesiologists, provides expertise in facility and anesthesia and pain billing. AAI’s approach to business echoes Dr. Binegar’s approach to his customer – it makes the practice feel “valued” and know that AAI will do what it takes to make things better. This has meant being responsive to his questions and concerns, providing great follow-up, and delivering information and reports that he needs. For example, when Dr. Binegar needed to know which procedures were profitable, AAI implemented a tracking system that provided data on payments by insurance carriers. Overall, AAI was and is very willing to work with Dr. Binegar and his staff and to grow with the practice. ABC is likewise delighted to continue supporting AAI and ABC clients in all their endeavors.

Starting or Growing Your Pain Practice

The decision to start or grow a pain practice is one that merits in-depth consideration – of market, lifestyle, finance, clinical expertise, referrals, human resources, facilities, etc. Dr. William Binegar’s success in building his pain practice provides a solid model for those posed to make such a decision.

For a review of factors to consider in starting a pain practice, see “Group Considerations in Anesthesia Group Pain Practices” by Paul Kennelly, AAI Regional Director, in this issue of the Communiqué.

Painful Considerations



Tony Mira,
President & CEO, ABC

It goes without saying that times are tough and money is tight. As a company, our auditors have prepared us for a five percent drop in revenues in 2009. We are not alone. Our clients are already starting to feel the cumulative effects of recession, consumer-driven healthcare and fewer elective cases. Because of this we are all tasked with exploring new and creative ways to maintain cash flow to support current salary and compensation levels for our clients. If ever there were a time for out of the box thinking, this is it.

All too often our clients tend to see themselves as captive to such host institutions and at effect of such market factors. This need not be the case. In this issue of Communiqué we explore just one possible avenue of opportunity: pain management. The argument for expanding the anesthesia practice into the realm of chronic pain is clear: few physicians are as adept at needle placement and the management of pain as those whose training in pharmacology and physiology makes them experts in the selection and administration of analgesics and the effective diagnosis and management of complicated symptomatology. For many the counter argument is equally as compelling: effective management of an outpatient pain practice represents a paradigm shift from the hospital-based service most of our clients provide so successfully and a potentially perilous diversion from core competencies.

In our quest for answers to these potentially perplexing questions we have called upon some of our most qualified staff and friendly clients to help you sort out the pros and cons, and practical considerations. Pain management is a broad term for a broader spectrum of practice options. No matter where you fall on the continuum, our contributions will take you from the general to the specific, allowing you to explore and contemplate the strategic and financial considerations of pain. Whether these ideas and insights allow you to further grow and develop your practice or the wisdom of caveat emptor, they are sure to pique your interest and challenge your assumptions.

As always, we strive to provide you with relevant contemporary experiences and practical tips and guidelines from across the company and across the country. Portland’s Ruth Morton profiles success factors for one client’s practice in our opening piece, while Seattle’s Paul Kennelly outlines how a pain management practice fits in the context of a larger anesthesia group. Pittsburgh’s Cathy Reifer then shares some of her research and knowledge of OIG risk areas. Atlanta’s Hal Nelson adds his list of the ten most common missed revenue opportunities for the pain practitioner. Deena Andrews in our Michigan headquarters contributes an explanation of the bell-shaped curve of evaluation and management services.

We also offer variety with a discussion of retirement plan options by Jill Thompson, information on important changes to the PQRI for 2009 along with some ideas on how PQRI pay-for-reporting will set the stage for pay-for-performance and pay-for-perfection from Karin Bierstein, an update from MGMA-AAA’s president, Brenda Dorman, on the social networking tool that has replaced the AAA list serv, and some insight into the future of diagnosis coding from Sharon Hughes. In this issue, we are also very pleased to offer you the reflections of the anesthesiologist who wrote “Have You Hugged Your Anesthesiologist Today?” We are sure you will recognize moments from your own professional lives in this beautiful entry from the author’s blog, Notes of an Anesthesioboist. These are all important aspects of the ever changing and always fascinating discipline we call anesthesia practice management. May they offer you new insights, stimulate your thinking about your own practice and, ultimately, help you plot the future of your practice.

Thanks for your continued support.

The Top 10 Lost Revenue Items in Chronic Pain Management

Hal Nelson, CPC
Director of Compliance and Client Services, ABC



Coding for chronic pain management is a challenging task. Each pain practice must be well versed in the billing nuances of this specialty. Otherwise, dollars are left on the table each day, without the practice even being aware of what it should be receiving for a case. Below if a list of the ten most common items that I have seen practices fail to document correctly and thus fail to receive full payment for a patient encounter.

1. Failure to document “bilateral” for facet joint injections. Fee schedule payments for these injections are for one side only. Bilateral injections need to be indicated on the superbill and procedural note. Coders need to double the charge for these injections and also need to append either the -50 (bilateral) modifier or the –LT and –RT modifiers in order for the payer to consider both injections for payment. Be careful not to document bilateral injections by using add-on codes, however (see Cathy Reifer’s article “The Government is Watching Facet Joint Injections” in this issue of the Communiqué).
2. Failure to document “bilateral” for transforaminal epidural injections. Fee schedule payments for these injections are for one side only. Bilateral injections need to be indicated on the superbill and procedural note. Coders need to double the charge for these injections and also need to append either the -50 (bilateral) modifier or the –LT and –RT modifiers in order for the payer to consider both injections for payment.
3. Failure to document “bilateral” for transforaminal joint injections. Fee schedule payments for these injections are for one side only. Bilateral injections need to be indicated on the superbill and procedural note. Coders need to double the charge for these injections and also need to append either the -50 (bilateral) modifier or the –LT and –RT modifiers in order for the payer to consider both injections for payment.
4. Failure to document fluoroscopy used for radiological guidance in pain injections. Almost all payers will reimburse for fluoro guidance used in association with pain injections. Yet many groups neglect to bill for this service. Coders should be aware that facets, transforaminals and SI joints cannot be done without fluoroscopic guidance.
5. Failure to document Consultations vs. New Patient Visits. When a patient is sent to a pain consultant to render an opinion and possibly initiate treatment, a consultation should be billed. Consults pay 25% more than a new patient visit code, so failure to bill for these codes can cost a practice a lot of money. Documentation needs to include a written request for the opinion from the referring physician and a copy of the consult note needs to be sent to the rendering physician after the encounter.
6. Failure to document IV conscious sedation. Sedation is often used by pain practices during injection procedures. IV conscious sedation is billable and is reimbursed by many payers. Be sure to document this item in order to receive full payment from insurance carriers.
7. Failure to document individual levels in a discogram study. Per the AMA, a pain physician can bill two codes for each disk evaluated in a discogram. One code is for the injection of dye and the other code is for the radiological supervision and interpretation. So when a practice bills for a three level discogram (i.e., L3-4, L4-5, L5-S1) six codes should be billed.
8. Failure to properly appeal unlisted procedures. Unlisted procedures are procedures which have not yet been assigned a CPT code by the AMA. Unlisted procedures will always be declined by payers without an accompanying medical necessity letter. These procedures can best be appealed by having peer review literature supporting the medical necessity for the procedure. Appeals should be sent to the attention of the medical director of the insurance company.
9. Failure to bill for ultrasonic guidance. Similar to fluoroscopic guidance, ultrasonic guidance can also be billed separately when used for guidance in pain injections. The difference is that with ultrasound, there needs to be an archived image of the ultrasound in the patient’s medical record in order to bill.
10. .Failure to document “counseling” or “coordination of care”. When a pain practitioner spends more than 50% of an office visit either counseling or coordinating care, the physician can use the total time spent on the encounter to substantiate the E&M code selected. This is the only occasion where time is used to select an E&M code in chronic pain management.

Group Considerations in Anesthesiologists' Pain Practices

Paul Kennelly
Anesthesiologists Associated, Inc. (AAI)

In a time of reduced reimbursement and decreasing OR activity, many anesthesia groups look for alternative revenue streams. They may entertain the idea of establishing a pain practice. As with all practice decisions, however, there are considerations and consequences to weigh. A pain service is not a panacea to cure the financial or staffing ills of an anesthesia practice and the decision to enter the market should not be taken lightly.

It is important to understand the difference between an anesthesia practice and a pain practice. Anesthesia is a hospital-based service, while a pain practice is considered office-based. A pain practice depends on steady referral business and physicians providing the service must be willing to cultivate and develop these referral sources (see Ruth Morton’s article “Building a Successful Pain Practice” in this issue of the Communiqué). It is here where many anesthesia groups face their first test. A service approach to both patient and referring physician is critical and failure to cultivate one can prove fatal. Often, anesthesia groups have physicians who have an interest in pain management but who are not prepared to devote their entire energy to the effort. Additionally, if a group’s culture is to view pain services as an adjunct to its core anesthesia business and not as a stand-alone practice which requires adequate resources, the pain service is destined to struggle. Unless the group decides they are “all in” they may find that this part-time approach yields more problems than expected. If your group is considering a part-time approach, make certain you understand the expectations of the marketplace and the ramifications that a part-time approach can have for your practice.

Operational matters such as call and vacation coverage should be discussed. How will the group respond to after-hour calls if the pain physician is unavailable and how will it cover the pain practice during vacations and other absences? Will the practice cancel the clinic when the pain physician is unavailable, on vacation, or caught in an OR case – and run the risks of damaging referral relationships and inconveniencing patients? Referral physicians and patients expect smooth access to coverage. Inconsistent service and a high hassle factor will shift their business to other providers.



Staffing may be an important factor for anesthesia practices when deciding on a pain practice if OR volume is low. Using the pain service as a safety valve to cover the operating room can be a short-term solution. Note the following caveats about such an approach. While it takes someone out of the OR rotation, groups may forget to plan for what happens when OR volume increases or pain referrals drop off. How will the practice respond when the pain physician wants to return to the OR pool on a full-time basis? How quickly can he or she come back in to the OR pool, and what is the impact on other pain providers when someone drops out of the pain service? In its most general terms a practice cannot allow the pain providers to simply roll in or out of the OR rotation based on the current economics of the group. Practices must have a clear understanding of how a clinician enters or exits the pain practice. The group should also address how the pain service fits into the OR call schedule. If the pain specialists are covering pain call they may balk at carrying an equal share of the anesthesia call. That means an increased call burden for the other members of the group.

Outline and agree clearly how the pain physicians will share in the group’s revenues and costs. Carving pain into its own compensation pool makes sense but decide up front how items such as overhead, call stipends, billing fees, and other practice expenses will be allocated to the pain pool.

Pain practice is on the radar for the payer community. It is very important to understand each of your payers’ policies and to investigate if the payer will negotiate a stand-alone pain contract. Review the agreement carefully to understand key issues such as pre-authorization requirements. In states that include pain medicine services in CRNAs’ scope of practice, some groups employing CRNAs may believe that the profit margin will be higher if they rely on lower cost providers to deliver pain care. This may be a red herring; some health plans may adjust their fee schedules to account for this difference. Be certain to evaluate the compensation exhibit carefully.

While a pain service makes sense for many groups, it is not for everyone. Give careful consideration when considering pain management as part of your practice ensuring you understand the internal dynamics and culture of your Group, the economics of your marketplace, who your competitors will be, and health plan reimbursement policies. Failure to address these issues may result in larger and more complex internal concerns for the practice. If the group is serious about developing a pain service, consider the use of a consultant conversant on group governance, pain billing, compliance, and market analysis to help with the process.

Understanding the Bell-Shaped Curve of Evaluation and Management Services

Deena Andrews, CPC
Coding Department Manager, ABC

Many practices at ABC not only perform anesthesia and pain medicine services, but also see patients for evaluation & management services (E&Ms). The reasons for providing these services vary. They include assessing chronic pain conditions or performing a history and physical to determine the appropriateness of anesthesia. Correct documentation and coding is essential to make sure that the documentation and coding represent what you did for the patient. In this article, we will attempt to give you some fundamentals of these services. We will also look at the bell shaped curve of E&M services.

When documenting an E&M service, the first thing a practitioner needs to decide is whether the patient is new or established. In general, a patient is considered new if he or she has not been seen by anyone of the same specialty in your group within the last 3 years. To clarify, if a provider has the specialty designation of either interventional or chronic pain and the patient had anesthesia by an anesthesiologist in the group without these designations in the last three years, the pain service can be billed as a new patient. On the other hand, if the pain physician does not have an interventional or chronic pain designation, and is billing under the anesthesiology designation, a new visit would not be billable. If a patient is not a new patient based on the above criteria, bill for an E&M service for an established patient.

The next step is to decide the type of service you will be performing: a consult or a visit. A consult can be billed when your opinion is requested by an appropriate source. If the referring provider wants you to take over the care of the patient for the particular condition, you will not have a consult, but a visit (e.g., if you received a referral script for injections). The other requirements of a consult are that there must be an order in the chart for the opinion (in both the requesting & consulting physician’s records), there must be a written report, and this report must be shared with the referring provider.



Should your evaluation not be for a new patient or a consult, you would be looking at a follow-up visit. Note that a follow-up visit is billable separately from and in addition to a procedure only approximately 1-2% of the time. The reason for this is that in order to bill for the visit you must have a separately identifiable diagnosis that does not relate to the procedure that is being performed. The evaluation of the patient prior to a procedure is included in the fee schedule for the procedure.

Once the questions above have been answered, one can move forward with the documentation of the evaluation and management service. The three primary components of an E&M service are: History, Examination, and Medical Decision Making. Another key consideration in deciding the level of service is medical necessity.



“Medical necessity” is the overarching criterion for payment, in addition to the components mentioned above. The volume of documentation should not be the primary influence for choosing a level of service. Therefore, after meeting the documentation requirements as stated above, determine whether the level of service is necessary for the condition evaluated.

All health insurance carriers compare data at national and local levels to target outliers for audits. In general terms, carriers expect the graph that represents the different levels (intensity) of E&M codes to take the shape of a bell curve. To help limit your practice’s vulnerability to an insurance audit, you should compare the data for your practice to national and local benchmarks. On page 8 is a graph (Figure 1) that represents national benchmarks for the second quarter of 2008 for consults and new visits in the ABC claims database. You will see the bell-shaped curve mentioned above. You will further observe that the intensity (CPT level I-V) of new visits skews to the left and the intensity of consults is skewed to the right. This skewing might be explained by the fact that consultations are by definition requested by another provider, which would indicate that the patient likely needs a more comprehensive evaluation than the typical Level III.

The second graph (Figure 2) represents follow-up visits. This includes (1) visits that were not performed in conjunction with a procedure, (2) visits that were performed in conjunction with a procedure but are separately billable and (3) visits that are not separately billable. You will see that there is the same bell shaped curve, but it is narrower. This is because follow-up visits tend to be non-crisis related and therefore would not have the extremes that you would have in consults and new patient visits.

The majority of practices do not follow the bell precisely. There are reasons why a provider might be skewed one way or the other. Some of the reasons for skewing to the left could be that hand-written notes are used. In ABC’s experience with hand-written notes, we find that these notes typically do not support higher levels of service. In the same vein, you might have such a busy practice that there is less time for thorough documentation and therefore, even though the work has been performed, it is not documented to the extent needed to support a higher level of service.



Reasons for the curve skewing to the right include the possibility that you have a newer practice. If so, you may be seeing higher acuity patients and spending more time with them. You also have more time for thorough documentation of your services since you have a smaller volume of patients. Another reason for a skew to the right could be that your practice has a high percentage of elderly patients whot require prolonged services for chronic illnesses. In ABC’s experience, the major factor contributing to higher levels of service is the use of electronic medical records (EMRs). EMRs, by nature, help the provider better document the services that are performed in a shorter period of time. An EMR also requires documentation at the time of service and that is when the details of the service that was delivered are in the physician’s immediate awareness.

There are other reasons for skewing to the left or right, but note that upon an audit either direction will be questioned. Your best strategy is to understand the rules for billing evaluation and management codes and to document correctly.
1. Health Care Quality and Measuring Performance
2. Proposed ICD-10 Rule Published
3. Cash Balance Plans
4. Have You Hugged Your Anesthesiologist Today?