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Winter 2009


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.