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Winter 2013

Three Common Issues

Joette Derricks, CPC, CHC, CMPE, CSSGB
Vice President of Regulatory Affairs & Research, ABC

The Centers for Medicare and Medicaid Services (CMS) Contractor Medical Directors (CMDs) recently put together a list of common CMS claim issues that were of concern to various contractors. Several of these items involve services that may impact anesthesia or pain management providers.

1. Use of modifier -59 for imaging with those procedures that now INCLUDE imaging in the code description and payment e.g. paravertebral joint/nerve blocks; transforaminal epidurals, many others.

In some cases, the base procedure includes fluoroscopy or CT imaging and the provider decides to perform the service under ultrasound guidance. Since the ultrasound guidance is not “bundled” in the base procedure description, coders are incorrectly appending modifier 59. However, the base procedure includes the payment for the fluoroscopy or CT imaging. It is incorrect to substitute the required and bundled imaging for another type that is not bundled and bill it separately.

2. Billing for “not qualified” personnel as “incident to” surgical assistants, scrub nurses, students, medical assistants, etc. in the outpatient facility setting in which CMS does not recognize services as being “incident to”.

The 2013 CPT Codebook “Instructions for Use of the CPT Codebook,” clearly distinguishes between a “physician or other qualified health care professional” and “clinical staff.” A “physician or other qualified healthcare professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service. These professionals are distinct from “clinical staff.” A clinical staff member is a person who works under the supervision of a physician or other qualified healthcare professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.

To qualify as “incident to,” services must be part of the physician patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. The physician does not have to be physically present in the patient’s treatment room while these services are provided, but they must provide direct supervision, that is, they must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for incident to service. For inpatient or outpatient hospital services and services to residents in a Part A covered hospital stay the unbundling provision (1862 (a)(14) provides that payment for all services are made to the hospital by a Medicare intermediary (except for certain professional services personally performed by physicians and other qualified health professionals). Therefore, incident to services are not separately billable to the carrier or payable under the physician fee schedule when rendered in the hospital setting.

3. Lack of medical necessity documentation for multiple joint injections and blocks.

CMS medical necessity provisions override all payment for all services rendered. Not being aware of either a national or local coverage guideline or the specific conditions for coverage of the service leads to documentation deficiencies that upon review will result in a denial of the services in question.

According to National Government Services (NGS) LCD for pain management the diagnosis of trigger points requires a detailed history and thorough physical examination. They will only pay for one trigger point injection procedure (CPT codes 20552 or 20553) on any particular day, no matter how many sites or regions are injected. In addition, NGS cautions that trigger point injections used on a routine basis, e.g., on a regular periodic and continuous basis, for patients with chronic non-malignant pain syndromes are not considered medically necessary.

Therapeutic intrathecal (subarachnoid) injections and infusions of opioid, local anesthetic, clonidine, and other medications may be used for the treatment of acute or chronic pain, cancer pain, and baclofen for intractable spasticity. The medical record should describe the presence of radicular pain or discogenic pain and the neuropathic diagnosis for the pain being treated. In addition, the medical record should indicate one or more of the following:

  • Conservative management has failed unless the patient has acute disabling and debilitating pain;
  • The patient is a candidate for surgery, but surgery is unacceptable to the patient or the patient is a poor surgical risk; and/or
  • The epidural injection is being performed as a therapeutic adjunct to a conservative therapy program, to provide temporary relief and in order to facilitate a more aggressive rehabilitative program.

Management of acute pain (obstetric, post-operative, or secondary to major trauma not requiring an operative procedure) in the hospital may be provided by several means: oral and parenteral administration of analgesics, intravenous patient controlled analgesia (PCA), and by the administration of epidural opiates or anesthetics. Epidural analgesia may be provided before or after a surgical procedure. Per NGS, payment for physician services related to patient controlled analgesia is included in the global fee paid to the surgeon. Routine management of PCA is not reimbursable to another physician or provider, and may not be billed as an anesthesia or evaluation and management (E&M) service. The prescription is part of the surgeon’s post-operative management and included in the global surgery. Catheters placed in an operative site for infusion of a local anesthetic are included in the global surgical package.

Anesthesia services provided by the performing surgeon are included in the global reimbursement for surgery, and neither the catheter placement (CPT code 62318 or 62319) nor the daily management of the administration of drugs is separately payable to the surgeon.

Daily management of epidural or subarachnoid drug administration is defined as a daily service and may only be billed by one provider other than the surgeon per day.

Joette Derricks, CPC, CHC, CMPE, CSSGB serves as Vice President of Regulatory Affairs and Research for ABC. She has 30+ years of healthcare financial management and business experience. Knowledgeable in third-party reimbursement, coding and compliance issues, Ms. Derricks works to ensure client operations are both productive and profitable. She is a long-standing member of MGMA, HCCA, AAPC and other associations. She is also a sought after nationally-acclaimed speaker, having presented at AHIMA, Ingenix, MGMA and HCCA national conferences. You can reach her at