Compliant Billing, Coding and Documentation for Interventional Pain Management
The word compliance keeps popping up in today’s healthcare environment, and after reading the Office of the Inspector General’s (OIG) Work plan for 2008; you can expect to see it much more often. So what are compliant billing, coding, and documentation? That question cannot simply be answered in one article, or in an eight-hour seminar. It is a process of integrating systems and policies into your practice—the most important of which is documentation.
In lecturing around the country on this topic, I am yet to have a physician raise their hands when I ask if anyone in attendance went into healthcare because of the documentation requirements. We all went into healthcare to help people, right? Well in order to continue to do so, documentation must take priority. Yes, I mean priority—and a transition into electronic medical records (EMR) is the only answer in order to be compliant. And, by the way, it’s a Federal mandate.
Why is compliancy one of the new buzzwords in the pain management specialty? Well, pain management is big business with 2 billion dollars being having been paid out by Medicare in 2005. With more individuals entering the Medicare system every day—together with the financial burden that comes with these growing numbers—it is no surprise that interventional pain management will be closely monitored. That translates into more frequent post-payment audits to insure that services were medically necessary.
Reasonable and Necessary Services
Section 1862(a)(1)(A) of the Social Security Act states that no payment may be made under part A or part B for any expenses incurred for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. In simplistic terms, the diagnostics and treatment must all have one goal for the patient, and that is to improve functional activities.
Initially, in preparing for this article, I was going to cover just the appropriate CPT codes to use when billing for epidural steroid injections and facet blocks procedures, but that would only be scratching the surface. In order to avoid having your practice red-flagged and possibly audited, I am going to delve into the medical necessity that is required to perform these procedures, as well as the billing and coding aspects.
Laying the foundation to establish medical necessity begins with the initial new patient encounter, whether it is a consultation or new patient code. What you choose as the level evaluation and management code (E/M) can impact whether your interventional procedures are deemed reasonable and necessary. The rationale would be based on the straightforward and simplistic medical decision-making component in these E/M levels. To further complicate matters, determinations of medical necessity vary by insurance carriers across the nation.
The following sections will utilize the Blue Cross/Blue Shield of California definitions to illustrate the complexity of proving medical necessity for facet and epidural injections. I encourage you to have your insurance staff research the medical necessity requirements in your state. A sample CPT coding table of the most commonly utilized for coding and billing of interventional procedures is also presented as an addendum to this article.
Complexity of Medical Necessity Determinations
Overall, the Blue Cross Blue Shield (BCBS) of California states that facet (cervical, thoracic, lumbar) or epidural (cervical, lumbar) injections are considered medically necessary when the following general criteria are met:
- A neurological/orthopedic/musculosk-eletal system evaluation is performed which includes a description of pain as it relates to location, quality, severity, duration/timing, context, and modifying factors, followed by a physical examination of associated signs and symptoms; and
- Conservative therapy (e.g., physical/ chiropractic therapy, oral analgesia/ steroids/relaxants, activity modification) fails or is not feasible.
- When pain relief is necessary for participation in physical therapy that would facilitate a return to activities of daily living.
- The patient’s response to therapy must be documented for medical review prior to additional therapy authorization.
As you can see from the first bullet, your choice of E/M level and documentation must provide validation in order to proceed to interventional procedures. BCBS of California elaborates further on the medical necessity of both facet injections and epidural steroid injections.
Criteria for Medical Necessity. Facet Injections—in the cervical, thoracic and lumbar regions of the spine—are divided into two phases: The diagnostic phase and the therapeutic phase. In the diagnostic phase, an injection is given and if there is pain relief (positive block), additional injections are given as part of the therapeutic phase. If there is no pain relief after the diagnostic injection (negative block), the therapy is not continued.
There are no historical, physical or imaging studies that are diagnostic of facet joint pain. The diagnosis is one of exclusion that is facilitated by performing a diagnostic block of the facet joint or nerves (medial branch of the posterior primary ramus) innervating the joints.
Diagnostic Phase. A diagnostic facet injection is considered medically necessary at the spinal level(s) in question when all of the following are met:
- The general criteria listed previously is met; and
- The pain is non-radicular; (i.e., for patients with a complaint of radiation of pain into an upper or lower extremity; radiculopathy, (a disorder of spinal nerve roots), has been ruled out by an MRI and no signs of dural tension as evidenced by negative “straight leg raise” on physical exam exists; and
- Suspected spinal facet joint syndrome as evidenced by low back pain exacerbated by extension and by prolonged standing/sitting that is relieved by rest; and
- Absence of a prior fusion at the clinically suspect levels; and
- Absence of an unexplained neurological deficit.
Diagnostic and therapeutic phase injection schedule. The following diagnostic and therapeutic injection schedule for facet blocks is considered medically necessary: