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11 Articles in Volume 7, Issue #9
CES in the Treatment of Addictions: A Review and Meta-Analysis
Chronic Cancer Pain Management
Compliant Billing, Coding and Documentation for Interventional Pain Management
Critical Transition from Short-to-Long-Acting Opioid Therapy
Dextrose Prolotherapy and Pain of Chronic TMJ Dysfunction
Dysfunction and Rehabilitation of the Shoulder
Low Level Laser Therapy (LLLT) - Part 2
Placebos in Pain Management
The Good Patient: Responsibilities and Obligations of the Patient-physician Relationship
TMJ Derangement and SUNCT Syndrome Co-morbidity
Ziconotide Combination Intrathecal Therapy

Compliant Billing, Coding and Documentation for Interventional Pain Management

A major increase in spinal disc surgeries and ensuing complications over the past 10 years have caused an increase in pain procedures to be performed—triggering, in part, increased scrutiny into pain management billing practices. With Medicare reimbursement cuts in pain procedures starting in 2008, it is important to understand what detail you have to document in order to prove medical necessity for your procedures. Not doing so will cost you lost revenue and, potentially, open your practice to a post-payment audit. Dr. Arkfeld is a popular lecturer, has written many published articles, and is both a C.P.C. (Certified Professional Coder) and an Independent Medical Examiner. He is also very tech savvy and has used a number of EMRs over the years.

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.

Facet 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:

  • When the previously listed criteria are met.
  • A diagnostic block of the joint or nerves innervating the joints using a local anesthetic with or without corticosteroids is given initially.
  • If the diagnostic block provides pain relief, a series of therapeutic facet injections are given no sooner than one week after a successful diagnostic block at that spinal region, (i.e., cervical, thoracic or lumbar).
    • The therapeutic frequency is limited to every 2 months per spinal region.
    • The maximum frequency of therapeutic spinal facet injections is six times per year.
  • If therapeutic facet injections are to be performed at a different spinal region, a positive diagnostic block is required at that region and the therapeutic frequency is limited to every 2 months for that region and therapeutic improvement is required for additional facet injections.

Not Medically Necessary Determination. Facet injections are considered not medically necessary:

  • When the above criteria for diagnostic facet injections are not met;
  • When there is a history of coagulopathy or systemic/local infection or unstable medical conditions;
  • For additional therapeutic facet injections in the absence of an improvement in pain or function;
  • For therapeutic facet injections more frequently than every 2 months per spinal region;
  • Therapeutic spinal facet injections more than six times per year;
  • In the presence of an unexplained neurological deficit.

Epidural Steroid Injections

Criteria for Medical Necessity. Epidural steroid (e.g., 40-80 mg. Methylprednisone acetate or 50 mg. Triacinolone diacetate) injections are directed at the neuroaxial compartment in the cervical and lumbar regions of the spine. Cervical and lumbar epidural steroid injections (ESI) are considered medically necessary when:

  • The general criteria listed previously are met; and
  • The pain symptoms are radicular as evidenced by physical examination, EMG or imaging.

Epidural steroid injection schedule.

Epidural steroid injections (ESI) are considered medically necessary:

  • When the previously listed general criteria are met.
  • The initial ESI is followed by reassessment not sooner than one week when the above criteria are met.
  • When partial improvement occurs after the first injection, the patient’s status is reassessed. Then an additional ESI may be performed, but not sooner than one week.
  • If further improvement has occurred after the second injection, a third injection may be performed not sooner than one week after the second injection.
  • If recurrence of symptoms occurs weeks or months after an initial favorable response to a series of 1-3 injections, an additional epidural steroid injection is indicated. (i.e., not to exceed a total of 4 injections per year).

Not Medically Necessary Determination. Cervical or lumbar epidural steroid injections are considered not medically necessary when:

  • There is a history of systemic infections, bleeding tendencies or unstable medical conditions.
  • Used for treatment of
  • non-radicular acute or chronic neck or low back pain;
  • myofascial pain syndrome, facet and sacroiliac arthropathy (even when accompanied by pain that radiates into an extremity);
  • spinal stenosis;
  • post herpetic neuralgia.
  • Used as an initial preconceived treatment plan of a series of three epidural steroid injections.
  • The injections are performed in the absence of documented improvement in pain or function upon reassessment.
  • Sustained improvement has occurred after the initial or subsequent epidural steroid injection.
  • Greater than four epidural steroid injections in one year.
  • When the primary injections do not provide improvements in pain relief and function.

Discussion

Considering the OIG’s 2008 work plan, and the need for detailed documentation to establish medical necessity, I urge each physician to assess the quality and ease in their current charting system. Frankly, evaluating the medical necessity whether a procedure is allowed based on the above-mentioned insurance requirements—which differ from state to state and insurance to insurance—will continue to become more complicated. Documenting and “catching” mistakes or “holes” in your documentation to avoid incomplete medically necessary information is very difficult in a manual and/or transcribed method. If you see an appreciable volume of patient load, it becomes almost impossible—without having a large support staff—to help you determine allowable medically necessary procedures. And we all know, more staff has its cost and other issues. I don’t know of any doctor that wants more staff.

The question is how you can keep on top of each patient’s case if you do not have continuously updated patient information at your fingertips. That is, have patient data collected and reported on the initial exam that is connected for all your follow ups. Patient data that helps you easily determine whether the injection you are about to do is medically necessary, documented as such and reimbursable. With the escalating complexities, insurance companies are prepared, with their sophisticated computer systems, to determine whether your procedural charges for a patient are in line with the rules. This is done by reviewing your billing practices and reports/notes. Reviews of your reports/notes in a post payment audit can financially cripple you and your practice.

The days of transcribing or manual note-taking are over because you will not be able to keep up with the new requirements manually. You see this in the federally mandated process that is in place to get all doctors computerized by 2013, as well as the proposed Medicare cuts starting in 2008. Unfortunately, the criteria is already being implemented in the form of payment denials and audits. You will need to be guided by an electronic system in order to be compliant. An electronic system that has the evaluative “connective patient” data I discussed above. For most of you, you have to “walk” before you “run.” If you have not transitioned into electronic medical records (EMR), now is the time. Communicating the need for interventional procedures effectively will determine if your office can withstand a post-payment audit without owing money back to the insurance carriers.

I believe the best defense will be in thorough electronic documentation via an EMR system that: 1) helps document your patient case, 2) helps guide you to the necessary steps for documenting correct E/M levels, and 3) provides expert guidance in the steps and decision-making needed to insure that you have presented a valid case for initial and follow-up pain management procedures.n

Addendum Billing/Coding Information: CPT Coding
62280 Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid
62281 Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic
62282 Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)
62310 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic
62311 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)
62318 Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic
62319 Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)
64479 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic
64480 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each addition level (list separately in addition to code for primary procedure)
64483 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level
64484 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (list separately in addition to code for primary procedure)
Note: CPT codes 62310 and 62311 are for “single injections (not via an indwelling catheter),” codes 62318 and 62319 are for “injection, including catheter placement, continuous infusion or intermittent bolus.” Therefore, billing any combination of these two sets of codes (62310-62311 and 62318-62319) would not be allowed for the same patient on the same date of service.

 

Last updated on: January 28, 2012
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