Avoid Pain Management Coding Pratfalls: 3 Tips from Quita Edwards of C.A.S.E. Contracting Services

Coding is a very detail-oriented process; however, certain surgical specialties require more documentation for procedures than others. Pain management, due to a high concentration of workers' compensation and motor vehicle accident cases, is one such specialty that requires extra attention by coders and medical staff.

Quita Edwards of C.A.S.E. Contracting Services discusses three suggestions for avoiding mistakes in pain management coding.

1. Make sure physicians are documenting using modifiers as opposed to multipliers. Procedures used to often be billed by unit — for example, a code times the number of times of physician made an injection. However, CMS and other payors now require coders to use modifiers, such as modifier -50, to designate when multiple injections are made. However, many physicians still bill by unit on their surgical reports.

"Surgery centers need to eliminate the use of billing by units because the documentation is not clear if physicians are injecting a level versus a nerve," Ms. Edwards says. "CMS recently added new codes for facet joints and other injections, so these modifiers need to be on the physician's superbill and the designation is needed to successfully process a claim."

Ms. Edwards suggests that surgery centers using electronic medical records make sure that their systems have the capability for coders, physicians and staff to select modifiers from the list of available codes. "Payments for bilateral factors also need to be factored, as insurers typically pay 100 percent for procedures done on the first side of the body and 50 percent for the second side," she notes.

2. Coders should bill only off the physician's surgical report. To expedite to the billing process, physicians will frequently provide ASC coders with a card that lists the codes used during a procedure, which is often generated by the physician's practice. According to Ms. Edwards, this is a huge problem in surgery centers.

"Often, there can be errors which were made on the physician's side on the cards from their offices, and if coders don't look at the surgical report, errors will be missed," Ms. Edwards says. "Coders need to take ownership of billing and claims, and ASCs should monitor that coders are coding from the operating report so that bills accurately reflect what went on in the operating room."

Ms. Edwards notes that one of the problems even seasoned coders can face is the tendency to code from habit as opposed to taking a close look at the surgical report. "Coding is repetitive, and most coders quickly memorize the top 15 or so codes that are used. However, this mindset can hurt an ASC and lead to lost revenue if the coder doesn't look at the body of the physician's note to make sure that he or she truly documents what was going on," she says.

3. Know the reimbursement rates of your top 5-10 payors. Payors often have widely differing rules for the coding of pain management procedures in ASCs. One sticking point for many payors is making sure that all conservative therapies were completed prior to the patient coming to the surgery center. According to Ms. Edwards, inaccurate documentation of prior treatment often leads to denials for pain management procedures in ASCs.

"It's important to know the reimbursement rates and what they will require and pay," she says. "The rules for Medicare are pretty straightforward, but surgery centers should know the rates for their top 5-10 private payors and know how they handle pain management."

Depending on the ASC, more than one physician group may be performing pain procedures at the center. Ms. Edwards says that is important to make sure that each group follows medical necessity requirements.

"Diagnosis codes are needed either from the payor or the provider and must be put on claims before they are sent out. The provider needs to clearly demonstrate medical necessity in the record. The ASC just sees the surgical report, so they need to check the requirements and hold claims for clarification if the information is not clear," Ms. Edwards says.

In order to address these concerns, Ms. Edwards encourages coders to communicate missing data to providers and to recommend to physicians that they include a paragraph at the beginning of the surgical report that supports the medical necessity of the procedure.

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