Understand Pain Management from an Auditor’s Perspective

Payers say unbundling of pain management codes is a real problem, and they’re on the lookout for offenders.

By Susan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRC

The number of providers offering pain management has grown considerably in recent years, with anesthesiologists, in particular, branching out to provide these services. As providers are billing more and more pain management services, payers are paying closer attention, and are finding cause for concern. Specifically, payers say they are finding a disturbing number of improper payments due to unbundling.

Unbundling Promises Pain

“Unbundling” occurs when services are reported with individual codes when there is a single code that encompasses all the services performed. As a coder, you must know what’s included with services to prevent this common coding error.

For example, coding guidelines clearly state that CPT® 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level is done under guidance. Yet, many providers additionally code CPT® 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid).

That’s unbundling. If a payer finds they paid separately for services that should have been included in another payment, they’ll want their money back (at a minimum).

As a second example, consider CPT® 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopic or CT); cervical or thoracic, single level: Here again, reporting the injection and guidance separately is unbundling. For procedures performed with ultrasound guidance, the proper code is 0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level. Check your documentation to determine your provider’s approach regarding guidance. If documentation does not support reporting the Category III code, inform your physicians of this requirement.

Bilateral Procedures
a Cause for Concern

What if a facet joint injection is performed on both sides of the cervical or thoracic joint? CPT® guidelines allow you to report 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level with modifier 50 Bilateral procedure, thereby gaining the provider a 50 percent reimbursement hike.

In the same situation just described, some providers will have the patient come in Monday for the right side injection, and then return Tuesday for the left side injection. With zero global days attached to 64490, there is nothing to say providers can’t treat their patients this way. But from a coding and auditing perspective, it’s a red flag if this occurs on every occasion. Some auditors find this to be an abusive way to increase revenue because the second procedure is reimbursed at 100 percent, rather than reduced to 50 percent payment when reported on the same day with modifier 50.

Note, however, that physicians providing these pain management services often administer the first injection as a unilateral treatment. If the patient tolerates the procedure, bilateral injections are provided for subsequent services. This practice, when documented, would support billing for the injections on separate days.

Differentiate Epidurogram from Fluoroscopic Guidance

Another troubling issue is providers who bill for an epidurogram (e.g., 72275 Epidurography, radiological supervision and interpretation) when fluoroscopic guidance is more appropriate.

For example, imaging is performed on the veins lining the spinal canal with an injection of contrast material under fluoroscopy, allowing the provider to examine the space surrounding the nerves to diagnose stenosis, herniations, and swelling. Often in such cases, documentation shows that fluoroscopic guidance, rather than epidurgraphy, was performed.

Report 72275 only when the images are documented and a separate report is issued. Because the service includes both technical and professional components, be sure to append modifier 26 Professional component when claiming only the physician work (e.g., the physician does not own the equipment and/or pay the staff). In cases where you are coding the facility portion (but not the physician’s work), append TC Technical component.

It’s likely the Office of Inspector General (OIG) 2014 Work Plan will investigate potential over-treatment in pain management, especially as it relates to unbundling and the “creative” coding done by some physicians.

Good advice: Audit your pain management claims now to ensure you’re on the right side of the law when a payer comes knocking.

Consider this example:

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The patient was taken to the operating room, placed in the prone position, and monitors were placed. The back was prepped with Betadine using sterile technique. An oblique fluoroscopic view was obtained. After alignment of the end plates, the superior articular process of each respective joint aligned with the adjacent pedicle. A 2 cc of Lidocaine 1% was infiltrated subcutaneously at the 6 o’clock position of the respected pedicle using a 27-gauge 1.5” needle. Following this a 22-gauge 3.5” spinal needle was introduced through the skin wheal and aimed for the 6 o’clock position of the pedicle. Bony contact was made and the needle was gently walked off and advanced into the transforaminal space under lateral fluoroscopic view. Confirmation needle placement was done using several AP, oblique, and lateral views. A 0.5 cc of Isovue® contrast medium was injected at each respective level in the AP view. Contrast medium was seen traversing the transforaminal epidural space medially, and along the respective nerve root laterally, and there was no intravascular uptake. This again was confirmed using multiple fluoroscopic views. Gentle aspiration proved negative for heme or CSF prior to injection of steroid solution. Next, a 3 cc solution was prepared using 1 cc of Lidocaine 0.5% (plain, preservative free) and 1 cc of Depo-Medrol® (40 mg/mL), and was injected without complication at each of the respective levels.

In this case, the provider wanted to report 72275—even though he states fluoroscopic views multiple times. Reporting a formal contrast study such as an epidurography requires a separate report, as well.

Take note: The documentation says “a 3 cc solution,” but in the chart note there are only 2 cc’s accounted for, leaving the coder to query the provider about the additional medication said to be used.

Susan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRC, is coding and billing manager for Travis C. Holcombe, MD. She has 20 years of coding and billing experience, is an AAPC workshop presenter and AAPC ICD-10 trainer, and served on the AAPC National Advisory Board (NAB) from 2007-2009. Ward was the 2012 president of the West Valley Glendale chapter, and has held offices with the Phoenix chapter. She is also a member of the 2012-2013 AAPCCA board of directors, region 8-West.

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