Take a Stab at Pain Management Coding
Here’s how to report a trio of PM needle procedures.
Pain management (PM) practices see a revolving door of patients needing relief from a variety of ailments. Often, these patients will require a procedure involving a needle.
And now that Medicare is (slowly) starting to loosen the restrictions on acupuncture, PM practices are using needle procedures even more often in the office setting. As acupuncture appears on its way toward wider payer acceptance, injections of onabotulinumtoxinA (Botox®) are also widely used for pain relief. Further, trigger point injections (TPIs) have been a tried and true PM procedure for a long time — and for a variety of pain problems.
Here’s a look at how PM practices can (possibly) get paid for acupuncture, along with a primer on reporting Botox® injections and TPIs.
Medicare Makes Acupuncture Rules Strict
Medicare began covering acupuncture in 2020, but that coverage is only for chronic low back pain (cLBP). “Also, there are strict NCD [National Coverage Determination] requirements to meet coverage criteria,” warns Toni Elhoms, CCS, CRC, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer, CEO of Alpha Coding Experts, LLC, in the Orlando, Fla., area.
For patients with documented cLBP, “Medicare will cover up to 12 acupuncture sessions over the course of 90 days, as well as an additional eight sessions for patients who show improvement,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pa. If a patient shows improvement, they could be eligible for another eight sessions a year. “Medicare patients will be limited to no more than 20 acupuncture sessions a year. Treatment must be stopped if the patient shows signs that they are not improving or are regressing,” says Falbo.
The Centers for Medicare & Medicaid Services (CMS) defines cLBP as pain that:
- Lasts 12 weeks or longer;
- Is nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
- Is not associated with surgery; and
- Is not associated with pregnancy.
Remember: These rules are for Medicare payers only. Elhoms reports that some third-party payers are reimbursing cLBP acupuncture services — but you should contact each non-Medicare payer individually, or check your contract, to see if they are covering acupuncture for cLBP.
When reporting acupuncture for cLBP, look to one or more of the following codes, depending on encounter specifics:
97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
+97811 without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)
97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
+97814 with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)
ABN alert: Consider obtaining a signed Advance Beneficiary Notice of Noncoverage (ABN) from Medicare patients scheduled for acupuncture for their cLBP. This ensures patients are advised of their options for having the service and their financial obligations should Medicare deny payment. Append modifier GA Waiver of liability statement issued as required by payer policy, individual case to the acupuncture code(s), as appropriate, to indicate an ABN has been obtained.
Bring J Code Knowledge to Botox® Claims
Whereas Medicare will only cover acupuncture services for patients with cLBP, providers employ Botox® injections for a wide variety of conditions. PM coders need to be intimately familiar with Botox® coding conventions or they could jeopardize their practice via under-coding (lowered payments) or over-coding (audits, other headaches).
Providers use Botox® to treat everything from migraines to hemorrhoids, says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. So, Botox® has a lot of uses in PM treatment — though you probably won’t code for hemorrhoid treatments in the PM specialty.
For each unit of Botox® your provider injects, you’ll report J0585 Injection, onabotulinumtoxinA, 1 unit. For example, if the PM provider injects two units of Botox®, report J0585 x 2 for the drug supply. Note that Botox® comes in 50- to 100-unit vials. Bill the number of units dispensed, not the number of vials.
You’ll also need to report a delivery code — most likely an injection code —to round out the claim. Here’s a list of the common injection codes used to report Botox® injections and the conditions typically associated with them:
64611 Chemodenervation of parotid and submandibular salivary glands, bilateral
Patients who drool due to neurological diseases, such as Parkinson’s, may require this treatment.
64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)
PM providers employ this procedure for patients with diagnoses such as blepharospasm (spasm of eyelid).
64615 muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)
Providers may use Botox® injections to treat patients with chronic migraine.
64616 neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
This treatment is for patients with painful and uncontrollable neck muscle spasms, a condition known as cervical dystonia or spasmodic torticollis.
64642 Chemodenervation of one extremity; 1-4 muscle(s)
Providers may employ these injections to treat patients who have spasticity, hemiplegia of the limb, cerebral palsy, etc.
+64643 each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure)
64644 Chemodenervation of one extremity; 5 or more muscles
+64645 each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure)
64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s)
64647 6 or more muscles
64650 Chemodenervation of eccrine glands; both axillae
A provider may perform this injection to treat a patient experiencing excessive sweating.
If the PM provider uses needle guidance during the Botox® injection, remember to report +95874 Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure) in addition to the supply code (J0585), the administration CPT® code, and the diagnosis code. (The diagnosis code is the clincher for reimbursement; payers do not cover Botox® for cosmetic procedures and consider it experimental for many other treatments.)
Aim at Muscle Count on TPI Code Choice
One of the standard and most widely employed needle procedures in PM practices is TPI. You can chalk up its frequent use to its versatility: Whereas other needle procedures target a single condition or a single anatomical area, your provider can use TPI to provide pain relief to a multitude of anatomical areas, for many different conditions.
The most common diagnoses for TPIs are muscle pain (myalgia), fibromyalgia, and myofascial pain syndrome. “Muscle spasm is also frequently reported,” explains Judith L Blaszczyk, RN, CPC, ACS-PM, ICDCT-CM, compliance auditor at ACE, Inc. in Overland Park, Kan.
When reporting TPIs, you’ll use the following codes, depending on encounter specifics:
20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
20553 Injection(s); single or multiple trigger point(s), 3 or more muscles
As you can see from the code descriptors, you’ll choose a TPI code based on the number of muscles the provider injects — not the number of injections the provider performs on a muscle. For this reason, “It is very important that the physician document each muscle that is injected so the coder can select the correct code,” Blaszczyk points out. Trigger points may occur in any skeletal muscle.
When a provider performs a TPI, you should be able to code separately for drugs, confirms Yvonne Bouvier, CPC, CEDC, at Degraff Memorial in Indianapolis. “For instance, the HCPCS J codes may be utilized to capture the steroid or corticosteroid medication,” she says.
Check out this list of drugs your provider may use during a TPI:
J0702 Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg
J2650 Injection, prednisolone acetate, up to 1 ml
Methylprednisolone (Medrol®, Depo-Medrol®, Solu-Medrol®)
J1030 Injection, methylprednisolone acetate, 40 mg
J1040 Injection, methylprednisolone acetate, 80 mg
J2920 Injection, methylprednisolone sodium succinate, up to 40 mg
J2930 Injection, methylprednisolone sodium succinate, up to 125 mg
This list is not definitive. Before reporting any TPI drug supplies, check with your providers about the drugs they use during TPIs, and check with your payers to verify which TPI drugs they consider reimbursable.