December 20, 2010

Find Relief From Pain Management Codes
By David Yeager
For The Record
Vol. 22 No. 23 P. 8

Pain management procedures can be particularly challenging for coders, partially due to the fact that many of these procedures are performed along the spine, an area of the body with a lot of moving parts and an array of codes to describe various diagnostic and therapeutic procedures. Another factor is the variety of drugs that may be used to treat those body parts. And when the injection location—in or between the vertebrae—is considered, correctly coding a pain management procedure can be as difficult as threading a needle.

“It’s all dependent upon where the needle is placed and, in some cases, what’s actually injected. The drug or medication may also drive the procedure codes,” says Marvel Hammer, RN, CCS-P, CPC, a pain management coding specialist and CEO at MJH Consulting. “We have a multitude of procedures that could be performed in the very small, narrow area along the spine and a wide assortment of codes that could be compliantly billed.”

While there are many ways to manage pain, such as prescription medications, radio-frequency ablation, electrothermal treatment, cryotherapy, and surgery, some patients with chronic pain respond better to injection therapies. A physician can relieve pain by numbing a nerve or entirely disrupting its ability to communicate with the brain, a process known as nerve destruction. Hammer says it’s important to know the purpose of the procedure because there are separate sets of codes for injections and nerve destructions. But it doesn’t necessarily get easier after that. She estimates there are 30-plus codes for injecting a local anesthetic in the spinal region, depending on the specific injection site and what’s injected.

Hammer says paravertebral facet joint procedures are some of the most difficult pain management procedures to code. Transforaminal epidural injections and sacroiliac joint procedures can also be troublesome. Aside from the different codes dictated by whether the procedure is an injection or a nerve destruction, physicians often report the spinal procedure levels differently, which can lead to ambiguity in the coding process.

“Some providers dictate based on the spinal nerve, the nerve that exits between two vertebrae: ‘C3, C4, C5 transforaminal epidural injection’ vs. those providers that document the transforaminal injections by the vertebral interspace: ‘C3-C4, C4-C5 transforaminal epidural injections,’” says Hammer. “In the first example, the physician is indicating three different levels that would equate to the primary code and two units of the add-on code. The second example is really two codes, the parent code and one unit of the add-on code. So just that little, subtle difference between a comma and a dash can change your coding and, potentially, even underreport the procedures.”

Because needle placement subtleties can have a significant effect on the codes, a good understanding of the different procedures and a strong knowledge of anatomy are necessary for proper coding. To ensure compliance, coders should match the procedure title with what is documented in the detail section of the procedure note. Hammer also recommends that coders specify whether a unilateral procedure was performed on the right or left side of the body to provide additional information to the payer, although it may not be required.

Of course, accurate documentation is essential, and coders should query the physician whenever they have a question about a procedure. This is especially true because it’s relatively easy for a typographical error to create a miscalculation with these types of procedures. For example, “C3C4C5” could be “C3,C4,C5” or “C3-C4 and C4-C5.” Mismatches in the number of spinal levels can not only lead to underreporting but also to overreporting, which Hammer says is a frequent error associated with pain management coding.

In addition, payers require the inclusion of a diagnosis code to indicate the medical necessity for the services billed, which means the anatomic region procedure codes must match the diagnosis code. For example, if a lumbar procedure is performed, a corresponding lumbar diagnosis code should also be billed. If the documentation points to either an unspecified ICD-9 code or an inaccurate spinal region, Hammer says it’s important to let the provider know what’s needed.

“All he needs to do is verify in his documentation pre- and postoperative diagnosis—which are routinely documented in procedure notes—to specify the spinal region,” says Hammer. “Be as specific as possible. Instead of, out of habit, noting low back pain or cervicalgia, if the physician has a confirmed diagnosis, such as lumbar disc herniation or C3-C4 disc degeneration, document the established diagnosis rather than continuing to report only the patient’s symptoms.”

Thorough documentation is likely to become more important in the next few years as payers are moving to increased medical necessity requirements for pain management procedures. Some payers’ coverage policies are starting to require detailed documentation of not only the change in the patient’s pain level but, additionally, the percentage and duration of pain relief and what, if any, functional changes the patient experienced during this time frame. Although recovery audit contractors haven’t yet targeted these codes, rising utilization rates for these procedures could be a harbinger of increased scrutiny. 2010 brought CPT code changes for paravertebral facet joint injections, and there will be similar changes for transforaminal epidural procedures beginning January 1, 2011.

“Because utilization, historically, has been going up, we’ve seen consequent increased scrutiny of both pain management procedure documentation and billing resulting in the code changes we are now seeing,” says Hammer. “For instance, with facet joint injections, it used to be structured where we had the parent code for the first level and an add-on code that was billed for each additional level. So if you injected four levels, you’d report the parent code and then three units of the ‘each additional’ code. With the CPT changes that became effective this year, the maximum you can bill are for three levels. If you inject four levels, that’s fine [but] you can only bill for three. The descriptor for the last add-on code is ‘third and any additional level(s).’ Code changes are one method to curtail escalating utilization.”

Looming ICD-10 changes will revamp the structure and reporting of pain management codes. The ICD-10 codes should alleviate some of the current problem points while adding greater specificity, such as whether a patient’s condition is unilateral—on the right or left side—or even bilateral, to more clearly represent potential medical necessity for interventional pain management procedures. Other features of ICD-10 will be the easier reporting of external use causes, more single combination codes to describe both the etiology and the manifestation, and better reporting of pain caused by trauma in accidents or Workers’ Compensation injuries.

“Instead of painting the patient’s condition in shades of gray, which we may be restricted in ICD-9, we’re now going to shift to shades of color,” says Hammer. “It will be a laborious change for a while but, after we reach full implementation, it will be a change for the good. In pain management, hopefully, ICD-10 will provide a better picture of the medical necessity of a particular procedure.”

— David Yeager is a freelance writer and editor based in Royersford, Pa.