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14 Articles in Volume 12, Issue #8
Board-certified Doctor Cleared of Criminal Charges for High-dose Opioid Prescribing
John F. Kennedy's Pain Story: From Autoimmune Disease To Centralized Pain
Key Clinical Pearls for Treating Headache Patients
Lest We Forget Pain Treatment Is a Stepladder Approach
Mathematical Model For Methadone Conversion Examined
Pain Management Coding Changes Can Sting, But Knowledge Can Help Ease the Pain
Pain Treatment—Then and Now
Platelet Rich Plasma Prolotherapy For Rotator Cuff Tears: Case Challenge
September 2012 Letters to the Editor
September 2012 Pain Research Updates
The Sports Injury-Pain Interface: Highlights from the American Orthopaedic Society for Sports Medicine Annual Meeting
Trigeminal Neuralgia: A Closer Look at This Enigmatic and Debilitating Disease
What Every Physician Should Know About Non-pharmaceutical Pediatric Pain Care
When Referring Patients, Not All Pain Specialists Are the Same

Pain Management Coding Changes Can Sting, But Knowledge Can Help Ease the Pain

5 Things You Need to Do to Remain Compliant With AMA CPT Coding Change

  • Have you reviewed the coding changes for 2012?
  • Have you updated your super bills and templates?
  • Is your revenue cycle management system updated and have your staff, including the procedure scheduler, been trained on the updates?
  • Are you prepared to handle the new trends in preauthorization/medical necessity requirements?
  • Is the staff able to manage the collections and appeals processes?

AMA CPT, American Medical Association’s Current Procedural Terminology


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.

Preauthorization Issues
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.

Codes 62318 and 62319 also contain changes to the coverage of injection procedures (including in-dwelling catheter placement, continuous infusion or intermittent bolus of diagnostic or therapeutic substance[s] such as anesthetic, antispasmodic, opioid, steroid, and other solution—but does not include neurolytic substances) and includes contrast for localization at all levels when performed, either epidural or subarachnoid.

Pain Pumps
For those pain specialists who are placing intrathecal or epidural drug infusion pumps, code 62367 has been changed to represent electronic analysis of a programmable, implanted pump without reprogramming or refill. Codes 62369and 62370 have been added to cover electronic analysis of a programmable implantable pump for intrathecal and epidural drug infusion—with reprogramming and refill represented by code 62369 and reprogramming and refill (requiring the skill of a physician) represented by code 62370.

Several new codes have been added for neurostimulators, and unfortunately, they are all in the Category III code series. This means additional difficulty with preauthorizations and payments. The code set of 0282T through 0285T include several related neurostimulator procedures that will need to be considered for those practices heavily involved in these case types.

It appears that several CPT descriptor changes were made in order to differentiate between open, percutaneous, and endoscopic approaches versus decompressive procedures via indirect image guidance for laminotomy/laminectomy (intralaminar approach) currently described in code 0275T, a new technology code. Code 0275T is for decompression of neural elements in the lumbar spine (with or without ligamentous resection, discectomy, facetectomy, and/or foraminotomy), any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral. Procedures performed in the cervical area are represented by code 0274T.

Additional notes in this series of coding scenarios direct us to codes 63020, 63030, and 63035 for a laminotomy (hemilaminectomy) performed using an open approach. Further clarification is described for percutaneous decompression of the nucleus pulposus of intervertebral disc, utilizing a needle-based technique allowing for code 62287. Code 62267 is a percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes. Adding to more confusion, CPT has language that is directly under code 62287 for decompression procedure percutaneous, indicating that this includes an endoscopic approach.

Coding changes for spine procedures include new vertebroplasty codes 22520, 22521, and 22522, which now cover the bone biopsy once performed at the same level as the vertebroplasty.

Last updated on: October 4, 2012
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