Pain Management Coding Changes Can Sting, But Knowledge Can Help Ease the Pain
OUCH! That is what I said when I reviewed the next set of changes for the 2012 pain management codes. After all, we had just gone through a series of changes for 2011. As physicians, you must comply with the new changes as required in the coding and reimbursement process, but getting your staff and carriers to update the submissions and reimbursements relative to these changes could be the biggest pain of all.
In 2011, several code changes were made in pain management. For example, interventionalists’ coding moved toward bundling “imaging” into “injections” along with several code set changes for neurostimulator and decompression procedures. We have also encountered several changes in insurance carrier criteria involving “medical necessity” and carrier-specific reimbursement guidelines that affected the reimbursement process. Look to your income differences per procedure to get a sense of how your individual practice has been affected.
Moving toward more restrictive carrier protocols has certainly reduced reimbursement by way of increased denials and intensive medical reviews of several of the procedures performed. So, to respond to these challenges, you will need to have your entire team collaborate on implementing programs that will update and formulate operational changes. Using a proactive methodology, as opposed to a refusal to adapt, will certainly reduce work in the end.
Pain management practices have been faced with several medical necessity issues, ranging from primary diagnosis supporting the procedures through documentation of the noninvasive treatments attempted before the procedures. Insurance carriers are looking to reduce costs in this area and have placed several restrictions on care if their coverage protocols have not been followed. When was the last time your practice researched these protocols to ensure compliance? It is disheartening to receive a denial for care based on the failure to follow the carrier’s medical necessity guidelines, and quite often the practice is left to adjust these balances due to the contractual restrictions or “bill the patient” if the procedure is not covered. Make sure to review the coverage protocols for your major carriers and develop a care map, if you will, to make certain that all the physicians and caregivers in your group are aware of the requirements before considering an invasive procedure. Quite often, the medical staff are unaware of the latest restrictions or requirements and continue to practice medicine based on their treatment philosophies. While the final decision on how best to care for the patient is solely between the physician and patient, ignorance of the process can be costly for all involved if the carrier refuses to reimburse for any given procedure.
As we all know, insurance carriers don’t always agree with treatment plans, and since they have the reins on reimbursement, it would behoove your practice to understand and implement programs that support the broadest range of treatment requirements. Yes, this is a tremendous amount of work, but will reduce the amount of coverage denials your patients receive. Generally, the information specific to medical necessity and coverage protocols are listed on the insurance carrier’s Web site, so it has become the responsibilities of the physician and staff to research and adjust accordingly.
Now to the Coding…
Before you become totally frustrated, we have listed the most prevalent coding changes in 2012 for ease of review (Table 1). But, this article does not usurp your responsibility to look to the American Medical Association’s Current Procedural Terminology (AMA CPT) guidelines or research carrier-specific criteria; however, we’ve provided for you a quick analysis of the coding changes. You will note that some codes have been deleted for injection procedures; new codes have been added; and, mostly, the imaging is bundled into these procedures. Some codes are for single-level procedures while others bundle multiple levels—please read carefully before applying any codes to these procedures. The most significant changes are in the “neurostimulator” and “decompression” areas. If your practice is involved in performing these procedures, be sure to select the coding that represents the case.
The following changes apply to pain management injection codes: 64633, 64634, 64635, and 64636 are added to describe destruction by neurolytic agent paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or computed tomography [CT]), cervical or thoracic, single facet joint; cervical or thoracic, each additional facet joint; lumbar or sacral, single facet joint; and lumbar or sacral, each additional facet joint, respectively. Imaging is now included in these codes is are not billable separately. All of these codes replace codes 64622 through 64627, which I believe have just been revised in recent CPT history.
We see the continuation of changes in injection codes, even though we’ve had the pleasure of significant changes last year. Code 27096 is for an injection procedure for the sacroiliac joint; it now incorporates image guidance (fluoroscopy or CT) including arthrography when performed. Therefore, there would not be separate billing for imaging.
Changes have also been made to codes 62310 and 62311. In addition to the actual injection of diagnostic or therapeutic substances (ie, anesthetic, antispasmodic, opioid, steroid, or other solution—but no neurolytic substances), the new codes cover needle or catheter placement, including the use of contrast material for confirming location.