Top 5 Errors in Pain Management Coding and Billing

With millions of people in the United States suffering from severe and ongoing pain – chronic pain management has become a significant public health problem costing our society billions of dollars in lost time and productivity while negatively impacting peoples’ lives. A recent report from the Centers for Disease Control (CDC) estimates that over 50 million people suffer from chronic pain, which equates to 20.4% or 1 in 5 adults.

With these numbers expected to grow as the population ages and the incidents of long-term pain from arthritis or other age-related conditions rises, pain medicine will continue to expand. With that comes added scrutiny from insurance payers trying to keep costs down by expanding prior authorization requirements, downward adjustments to fee schedules, and shifting financial responsibility to the patient.

Eliminating the Top 5 Errors in Pain Medicine Coding

It’s more important than ever to ensure a state-of-the-art revenue cycle management process that includes solid coding and billing practices. Let’s look at the top five errors pain medicine practices make when coding visits to ensure maximized reimbursement now and in the future:

  1. Not Providing Documentation Appropriate for the Visit — Accurate and complete documentation is more important than ever in pain medicine, with denials being issued due to missing information on various issues, i.e., laterality or which nerves were treated. Providers must include thorough, accurate treatment information in the original operative note or an addendum. Once sent to the business department, coders must be experts at clarifying information found in the notes and coding appropriately based on the latest coding guidelines.

  2. Not Staying Up-to-Date on Payer Policies and Guidelines — Providers and coders need to stay current on insurance payer policy changes to ensure maximum reimbursement. Sometimes this requires detective work to glean information from updates and documentation from a vast array of insurance payers.

    With coding and billing, the significant changes are usually announced in the final quarter of the previous year with effective January 1st. However, information can change throughout the year. A good example has been the telehealth changes that impacted patient E/M codes and ICD-10-CM codes during the COVID-19 pandemic.

  3. Billing Fluoroscopy Separately — Many pain management practices bill for fluoroscopy separately from the procedure. Be sure to understand if this is a bundled charge for the procedure used, i.e., SI joint (27096), medial branch blocks, and facet injections. Or if it is recognized separately, i.e., fluoro guidance codes for peripheral joints.

  4. Use of Modifiers in Pain Medicine — Modifiers exist to clarify the service or procedure done and can make a significant impact on revenue when missed or misused triggers denials. Consider the following:

    • LT – anatomically left
    • RT – anatomically right
    • 50 – bilateral
    • 59 – notes that a service or procedure is independent and separate from other services that were performed on that same day
    • 52 – incomplete procedure – stopping part of the procedure due to reasons other than patient well-being
    • 53 – incomplete procedure – the physician chooses to end a procedure for the patient’s well-being
  5. Exceeding Limits on Approved #’s of Procedures — Pain medicine requires careful oversight of numbers of procedures performed compared to approved visits allowed. Exceeding the limit prescribed is quite common and will be disallowed.

When reviewing your pain management medical coding and billing program, it’s critical to avoid anything that might trigger a post-service prepayment coding review from insurance payers. Coding reviews can add up to 180 days to payment times and devastate the bottom-line.

An alternative may be to consider engaging a third-party partner who has the expertise to code and bill efficiently and scale without issue and maintain the training and updating required to stay at top form.

Contact us to learn more about our premier medical coding and billing services.

About the Author

Infinx
Infinx Healthcare provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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