AAOS Now

Published 12/31/2019
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Cheryl Toth, MBA

Does Your Practice Treat Pain?

Get your payer coverage policies and E/M coding and documentation in order

Interventional pain management is a growing specialty, and many orthopaedic groups have added an interventionalist to the physician team. If this is the case for your practice, make sure the interventionalist understands the reimbursement and documentation nuances essential to optimizing payment and mitigating payer takeback risk.

“The biggest problem we see is that interventional pain physicians don’t follow payer coverage policies for medical necessity that dictate when they can perform an intervention and get paid,” said Teri Romano, BSN, MBA, CPC, CMDP, a senior consultant at Karen Zupko & Associates, Inc. (KZA). “From trigger point injections to joint injections to spine injections, payer coverage policies outline the criteria for meeting medical necessity. They are very specific and very detailed. Medicare and almost [all private payers] have them.”

Ms. Romano said that payers make the policies easily available online. Yet many interventionalists have not effectively integrated them into their coding or revenue cycle processes, which can lead to denial and potentially payer takebacks.

For instance, Ms. Romano often finds that interventionalists determine that patients may benefit from injection and give them without knowing or following policy requirements. “The patient’s plan might require a six-week trial of conservative care such as medication and therapy or specify requirements based on the diagnosis code,” she explained. “If the physician doesn’t follow the policy, the payer will deny the claim because it’s considered ‘not medically necessary’ to give the injection” until after a trial of conservative therapy.

Deborah Grider, CPC, COC, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, a senior consultant at KZA, said the root of the problem is that practices are not proactive. “Every year, staff must update these policies for the practice’s top payers,” she said. “They need to go online; pull them down; and create a spreadsheet, list, or card that will alert the doctors about parameters that must be met before a patient is given an injection or procedure.” Some electronic medical records can be modified to embed procedure-
specific medical necessity criteria as part of physician documentation templates.

Ms. Romano agreed, referring to this process as coverage policy management. She suggested creating a spreadsheet that includes a column for each payer and rows for each of the physician’s common procedures. The key, Ms. Romano and Ms. Grider said, is to create an easy way to keep physicians informed about the rules and requirements. “The medical policy protocols differ by payer, but they have to be followed in order to get paid,” said Ms. Grider.

And although carrier policies and documentation requirements should be considered and documented, Ms. Romano said that an injection or intervention should always be provided when the physician feels it is clinically indicated. “In these cases, it’s appropriate to inform the patient that the carrier may not provide reimbursement and ask him or her to sign a waiver,” she added. Such waivers then enable a practice to collect from patients.

Watch out for modifier 25 overuse

Modifier 25 indicates to payers that a separate identifiable procedure was performed on the same day as an evaluation and management (E/M) service. But Ms. Grider and Ms. Romano regularly see interventionalists use the modifier incorrectly and too frequently.

Overuse of modifier 25 is due to the common misconception that, during subsequent visits for injections, a
physician can bill an E/M service on that same day. Ms. Romano warned that an E/M is rarely justified in such cases. “On the first visit, when the physician makes a diagnosis, he or she can bill for an E/M service,” she explained. If an injection is given at the first visit, the E/M code would be appended with a modifier 25 to indicate that a separate and identifiable service was performed.

Many patients experiencing pain are sequential users, and when they come back for another injection for pain in the same area, another E/M code cannot be reported, explained Ms. Romano. “You’ve already made the diagnosis, and every procedure has some inherent E/M service included. If it’s recurring pain in the same area and you already diagnosed it, you can only bill for the injection when they come back” for a subsequent injection, she said.

Ms. Grider shared the story of a physician who incorrectly billed so many E/M services with modifier 25 that payers now require every claim to be reviewed before it is processed for payment. “We’re trying to help the practice appeal some of the visits, but I think it’s futile,” said Ms. Grider. “It’s clear that the visit was for an injection, not an evaluation.”

Ms. Romano warned that payers are analyzing E/M coding patterns when a physician has already made a diagnosis. “If the chief complaint is Return to evaluate pain relief or Return for injection, the patient is coming back for the same thing. Same pain; same area. No E/M service should be billed.”

“Interventional pain is on the hot seat, given opioid abuses and questions about medical necessity for giving an injection,” said Ms. Grider. “Payers are saying, ‘Prove it,’ and there are a lot more audits to make sure that the injection was needed and the physician adhered to the payer’s coverage policies; it’s more important than ever to do things right.”

Improve E/M documentation and consider a plan of care

When it comes to E/M coding, Ms. Grider said interventionalists document exams pretty well, but “History-taking is very poor. There’s little detail about [what] protocols have been tried and failed or the history of chronic pain. Interventionalists do a good job documenting the patient’s present condition but don’t go far enough into the history to identify the criteria that must be met for medical necessity.”

For instance, if a patient has chronic pain, an interventionalist’s documentation often does not indicate the status of the condition. “The note will say, Continue same or Patient will return in three months.”

Instead, Ms. Grider said, interventionalists must outline the details of a patient’s plan. To make this easier, she recommends that each physician develop a pain care plan that puts into writing the physician’s standard clinical pathway for treating pain. “Include the details about modalities, protocols, and treatment guidelines for various conditions and patient types,” she explained. “Then use this document as a template to create a unique pain care plan for each patient, and store it as a separate document in the patient’s medical record. Every time you see the patient, follow the protocols of the plan.”

Ms. Grider suggested drafting each patient’s plan to include details from his or her payer policy so it’s easier to determine whether the patient can receive another injection. With one client, she helped develop a standard care plan for shoulder, back, and knee pain. “We included the general clinical parameters he followed, along with payer policies. Now when the physician is with a patient, he can look at his standard pathway compared to the patient’s plan and know which requirements he has to follow.”

For a physician who had more than 500 claims denied in a six-month period, Ms. Grider worked to create a general care plan and then integrated payer policies. “We had an information technology person build the plan elements into the electronic health record so the physician can point and click to develop a custom plan for each patient.”

Although such plans of care are not required by payers, Ms. Grider said they are beneficial because when payers request additional documentation or staff are appealing denials, they can provide comprehensive details about a patient’s condition and progress. “It’s an added layer of validation that the physician followed the medical necessity policy in alignment with his or her standard plan of care.”

AAOS partners with KZA on the organization’s coding education. For more information, visit www.aaos.org/membership/coding-and-reimbursement.

Cheryl Toth, MBA, is director of content development at KZA.