Pain Management Coding.

Proper coding and billing of pain management services rates a discomfort level of about 8 on the 10-point McGill pain pattern scale. Medicare coverage guidelines vary from state to state. Because pain management reimbursement policies are carrier-specific, practices should review local medical review policy for each type of procedure performed. Medicare's billing guidelines do not always correspond to medical practice. Non-Medicare carriers, private and noncommercial carriers, may provide reimbursement for services that are routinely denied for coverage by Medicare. Contact each payer to be certain of its policy.

PAIN MANAGEMENT CONSULTATIONS VS NEW PATIENT

Pain management consultations are carefully watched for abuse; Medicare has targeted office codes 99241-99245 and hospital codes 9925 1-99255 for careful scrutiny. The documentation required from the surgeon when requesting a postoperative pain consultation is usually a note in the inpatient or surgical medical record, if requested immediately following surgery. If the postoperative pain consultation is for the patient following discharge, the following three criteria must be met to bill for consultation:

(1) The request for consultation must be from another physician or "other appropriate source,"

(2) the request must be documented in the patient's record, and

(3) formal communication must be made back to the surgeon from the consultant.

A clear understanding of the definition of a consultation is required in order to avoid improper billing. A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit. Medicare states that a consulting physician can treat in an emergency or order diagnostic tests to help render a decision, but he or she was asked for a "consult" or "to evaluate" only. In outpatient pain management, the patient is generally referred and should be billed as a new outpatient evaluation.

EPIDURAL CATHETER PLACEMENT

Physicians place epidural catheters for postoperative pain management at any of four sites along the spine. Placement of a cervical or thoracic catheter is coded 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). Placement of a lumbar or sacral catheter is coded 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 Es] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar or sacral [caudal]). Postoperative pain management of the catheters is coded 01996 (daily management of epi dural or subarachnoid drug administration).

Medicare will pay for placement of an epidural catheter if placed solely for postoperative pain management. The patient's anesthesia record must indicate that the catheter administered no continuous anesthetic during the operative procedure. Supporting documentation should include the anesthesia record that indicates general anesthetic was administered other than through the epidural catheter.

If the catheter is used during the surgery to administer anesthesia, the placement is bundled into the global anesthesia service and may not be billed separately.

TRIGGER POINT INJECTIONS

Trigger point injections should be coded according to the muscle groups targeted, not according to the number of injections administered. Even if multiple injections are administered at the same site, only a single injection should be coded. Carriers limit the coverage for the number of injections per session, so it is best to check the specific carrier's policy.

Medicare carriers use software edits to identify and prevent unbundling. Using modifier -59 (distinct procedural service) indicates that the physician injected different muscle groups, thus overriding the software edit. A different modifier that is sometimes required is modifier -51 (multiple procedures). Check the specific carrier's requirement before using the multiple procedures modifier because the multiple procedure reduction applies to modifier -51. As with all multiple procedures, the first injection is reimbursed at 100%, but payments will be reduced by 50% for each subsequent injection.

An important distinction should be made regarding multiple procedure payment reduction and add-on codes. CPT lists a summary of add-on codes in Appendix E and a summary of CPT codes that are exempt from the use of modifier -51 but have not been designated as CPT add-on procedure/services in Appendix F of the CPT code book. Add-on procedure codes have already been reduced for payment. Adding modifier -51 to an add-on code will reduce the payment further. It is important to identify codes that are either add-on codes or modifier -51-exempt.

Complete documentation is critical in establishing medical necessity for trigger point injections. Injections of trigger points 20550, will be covered when all of the following criteria are met:

(1) The patient's clinical condition is marked by substantial pain and/or significant functional disability,

(2) appropriate conservative treatment has not provided acceptable relief, and

(3) there is a reasonable likelihood that the injection will significantly improve the patient's pain and/or functional disability.

For subsequent trigger point injections, those received in a series, the patient's medical record must state the degree of relief the patient experienced from the previous injection. For example, the physician should document "the patient reports that the second trigger point series to the affected muscle group provided 30% relief."

BOTOX INJECTIONS

Botulinum toxin type A (Botox) injections are indicated for spastic conditions that have been unresponsive to traditional methods of treatment. These injections are used to reduce excessive muscle contractions, thereby relieving pain and increasing range of motion. Botox is a potent neuromuscular blocking agent with good selectivity and duration of action and few side effects. It is essential that the documentation state and describe the treatment methods, medication, and/or therapy that have been tried unsuccessfully. Diagnosis codes that support medical necessity are carrier-specific, making it important that the physician state the covered diagnosis as part of the documentation.

Botulinum toxin is very expensive and once opened, has only a 4-hour shelf life. Two or three patients can be treated with one 100-unit vial. To reduce waste, patients receiving Botox injections should be scheduled on the same day, in succession when possible. The muscle site of the injection must be specified, as well as the number of units injected. The patient's medical record and each claim form filed should indicate the number of units injected into the patient, as well as the exact amount of the discarded portion of the vial. Medicare will allow only one payment per injection site, regardless of the number of injections made into that site. Medicare guidelines on the use of Botox limit payment to only one injection per site every 90 days. If two maximum dose Botox treatments in a row fail, Medicare restricts reimbursement for further injections within a year.

CONSCIOUS SEDATION

Conscious sedation is defined as sedation with or without analgesia that is used to achieve a medically controlled state of depressed consciousness while maintaining the patient's airway, protective reflexes, and ability to respond to stimulation or verbal commands. New codes were added to CPT in 1998 to describe conscious sedation services reported by physicians other than anesthesiologists or nurse anesthetists. CPT code 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular, or inhalation) and 99142 (sedation with or without analgesia [conscious sedation]; oral, rectal, and/or intranasal) cannot be billed unless they are performed in the physician's own office. These codes require the presence of an "independent trained observer" to assist the physician in monitoring the patient's vital signs, level of consciousness, and physiologic status during the procedure. The independent trained observer, a nurse or physician's assistant, must be employed by the practice. Documenta tion must include performance of pre- and post-sedation evaluations of the patient, administration of the sedation and/or analgesic agent(s), and monitoring of cardiorespiratory functions (ie, pulse oximetry, cardiorespiratory monitoring, and blood pressure measurement).

Most local Medicare carriers state that conscious sedation is included in the primary procedure. Because conscious sedation policies are carrier-specific, practices should contact their payer to determine their policy. While Medicare does not pay for this service, some private and noncommercial carriers do reimburse for conscious sedation.

MONITORED ANESTHESIA CARE 

With advances in modern medical technology, there has been a change in the provision in anesthesia services from the traditional anesthetic to a combination of local, regional, and certain mind-altering drugs. This type of anesthesia is referred to as monitored anesthesia care (MAC) if directly provided by qualified anesthesia personnel. MAC is typically provided to combative patients, those with low pain thresholds who suffer severe pain, or those with severe health problems that require careful monitoring.

MAC requires careful and continuous evaluation of various vital physiologic functions and the diagnosis and treatment of any deviations. Medicare allows coverage for MAC if the anesthesia service is reasonable and medically necessary. Close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions. Also, the possibility that the surgical procedure may be more extensive, and/or result in unforeseen complications, requires comprehensive monitoring and/or anesthetic intervention.

The requirement for this type of anesthesia should be the same as for general anesthesia with regard to the performance of preanesthetic examination and evaluation, prescription of the anesthesia care required, the completion of an anesthesia record, the administration of necessary oral or parenteral medications, and the provision of indicated postoperative anesthesia care. Appropriate documentation must be available and must reflect pre- and post- anesthetic evaluations and intraoperative monitoring. Reimbursement for MAC should be the same amount allowed for full general anesthesia services. Medicare will reimburse only if the physician is present in the operating room.

PAIN PUMP REFILLING AND PROGRAMMING (WITHIN THE GLOBAL PERIOD)

Many procedures combine a professional and a technical component. Modifier -26 is attached to the CPT code to indicate that the physician performed only the professional component of a service. Modifier -TC signifies that only the technical component was provided. When the procedure is performed in a physician's office (owned and operated by a physician) no modifier should be appended to the CPT code. Codes 62368 (electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion [includes evaluation of reservoir status, alarm status, drug prescription status]; with reprogramming) and 96530 (refilling and maintenance of implantable pump or reservoir) are used to bill for the refilling and reprogramming of a pain pump in the physician's office. When a procedure is done at a hospital or when the physician does not own the equipment, modifier -26 is usually required.

Billing for the refill or reprogramming of a pump may be denied initially because the implantation of the pump has a 90-day global period. To overcome this, modifier -58 (staged or related procedure) should be appended to codes 62368 and 96530 when performed during the postoperative period. Check with the specific carrier before billing HCPCS code A4220 (refill kit for implantable infusion pump). Some carriers consider this bundled into the refill and reprogramming payment.

FLUIDIZED THERAPY DRY HEAT FOR MUSCULOSKELETAL DISORDERS

Fluidized therapy is a high-intensity heat modality consisting of a dry whirlpool of finely divided solid particles suspended in a heated air stream, the mixture having the properties of a liquid. Use of fluidized therapy dry heat is covered as an acceptable alternative to other heat therapy modalities in the treatment of acute or subacute traumatic or nontraumatic musculoskeletal disorders of the extremities.

NON-COVERED TREATMENT AND THERAPIES

Acupuncture

Until the pending scientific assessment of the technique has been completed and its efficacy has been established, Medicare reimbursement for acupuncture, as an anesthetic or as an analgesic or for other therapeutic purposes, may not be made. Accordingly, acupuncture is not considered reasonable and necessary within the meaning of the Medicare Act.

Although acupuncture has been used for thousands of years in China and for decades in parts of Europe, it is a new agent of unknown use and efficacy in the Unites States. Even in those areas of the world where it has been widely used, its mechanism is not known. Three units of the National Institutes of Health--the National Institute of General Medical Sciences, National Institute Neurological Disorders and Stroke, and Fogarty International Center--have been designed to assess and identify specific opportunities and needs for research attending the use of acupuncture for surgical anesthesia and relief of chronic pain.

Prolotherapy for Chronic Low Back Pain

The term "prolotherapy" is a derivation of "proliferative injection therapy" and is also known as sclerotherapy or proliferant therapy. The practice of prolotherapy is used by doctors of osteopathy and other physicians to treat a number of different types of chronic pain. Prolotherapy is a collagen-strengthening injection technique that targets the soft tissues of the lower back by injecting solutions at the interface between bone and tendon, ligament, or fascia to provoke an inflammatory response resulting in collagen proliferation. Prolotherapy consists of a series of intraligamentous and intratendinous injections of solutions in trigger points near the painful area to induce the proliferation of new cells.

Medicare does not cover prolotherapy, joint sclerotherapy, and ligamentous injections with sclerosing agents. The medical effectiveness of these treatments has not been verified by scientifically controlled studies. Reimbursement for these modalities is denied on the ground that they are not reasonable and necessary as required by the Social Security Act.

Vertebral Axial Decompression (VAX-D)

Vertebral axial decompression is performed for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. There are insufficient scientific data to support the benefits of this technique. Therefore, Medicare does not cover VAX-D.