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Understanding the art and science of pain management coding

Ambulatory surgery centers are on the front lines of the nation’s chronic pain epidemic.

An estimated 100 million Americans live in chronic pain, a condition that is expected to cost as much as $635 billion in annual treatment expenses and lost productivity, according to the Institute of Medicine.
Pain management is unique among the various specialty areas of medicine typically performed at ASCs. From a clinical standpoint, chronic pain frequently can only be managed, not cured. That means, unlike a bad knee or hip, an outpatient procedure often does not alleviate all of a pain sufferer's symptoms.

Complicating matters, the underlying issue that's causing the pain might not always be clear. Patients also return frequently for follow-up appointments, so their physicians can check on their progress. Some physicians also aggressively treat pain sufferers, while others are more conservative in their approach.

These differences in clinical care extend to an ASC's billing and coding operations. For example, most payers limit radiofrequency ablation, a common long-term pain management procedure for chronic pain sufferers, to once every six to12 months. Meanwhile, it's not uncommon for physicians to recommend the procedure more frequently for some patients. The result? Unhappy patients and lost revenue. Some payers also limit the number of spinal injection procedures that can be performed on a patient in a year or during a lifetime. Making sure that you know and understand payer policies regarding these procedures can help limit denials.

This discrepancy is just one of the many reimbursement issues unique to treating chronic pain sufferers. Here are four best practices for preventing potential pain management billing and coding issues at your ASC:

Document correctly

Documentation is paramount. Without proper documentation by physicians, pain management procedures can be deceptively difficult to code. Insufficient documentation requires follow-up queries with doctors, which causes them to take additional time out of their busy days, creates operational inefficiencies and delays billing — or worse.

For example, medial branch nerve injections. While these injections are performed at the pair of medial branch nerves that innervate the facet joint, physicians need to clearly document exactly which nerves, or at which facet joint(s), these injections are being performed to ensure the proper number of levels injected are being coded. Not being specific in these cases can result in over coding (too many levels) or under coding (too few levels), which could result in overpayment or under payment.

Educate physicians and staff

Open communication between physicians and staff can make or break a busy ASC. For coding and billing departments, it’s imperative to meet regularly with physicians to discuss current issues and process bottlenecks that may be hindering a facility’s productivity. Structured seminars are a productive way to walk through common coding, billing and documentation issues with physicians. These settings also provide an opportunity to generate valuable feedback from physicians because, after all, coders are not in the room when the procedures are performed.

Many ASCs hold scheduled monthly meetings with physicians and the billing department to discuss issues that have arisen in the previous weeks. In these meetings, billing staff can discuss specific cases where notes were not specific enough, or provide examples of cases that included insufficient documentation.

Coders should continue to educate themselves on the structure and function of the human body. With a greater understanding of anatomy, coders and physicians can speak a common language that enhances communication and improves understanding of the procedures performed, leading to greater accuracy in coding. Coding rules also are continually changing, so it’s very important that coders stay current on the latest updates, rules and guidelines — and educate physicians accordingly.

Master EHR systems

Electronic health records systems are here to stay. Mandated by federal law, these virtual platforms were designed to replace the cavernous, back-office filing rooms that once were a mainstay in healthcare facilities.

Intended to create efficiencies and allow physicians and specialists to collaborate on patient care, EHR systems often require substantial user training for physicians and staff, especially in pain management. For example, the complexities of pain management makes it difficult to design convenient drop-down menus on an EHR system’s user interface. That means physicians often need additional training on how pain management procedures should be articulated in the on-screen text boxes.

Relate coding to the bottom line

Like all businesses, money talks in healthcare. Many ASCs are joint ventures among physicians, hospitals and/or outside investors. If bills do not accurately represent the procedures that were performed at the facility, the ASC and each physician likely will suffer financially because of it.

This issue is particularly acute in pain management, a specialty in which coding can seem more like an art than science. Reminding physicians that insufficient or incomplete documentation can directly result in under billing or over billing often underscores to them what’s at stake, i.e. their personal financial livelihood.

Chronic pain management is expected to be a growing area of specialty medicine in the coming decades. According to the Pew Research Center, between now and 2029, an estimated 10,000 baby boomers per day will reach retirement age – and with it, the aches and pains of the aging process. By creating a thorough narrative of each patient’s treatments, collaborating together and implementing technology, ASCs can lead the way in improving patient satisfaction, treatment options and financial models in chronic pain management.


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