Neurology & Pain Management Coding Alert

Hint: Stay away from reporting one service, even with thorough documentation.

When your pain management specialist provides postoperative care for a patient, ensure payment by having every step of the process documented. Our experts share their best advice on post-op pain management coding, from surgical request to final chart.

1. Get the Request in Writing

The Correct Coding Initiative's (CCI's) guidance indicates that routine postoperative pain management services are included in the global surgical fee and cannot be reported by an anesthesiologist or pain management specialist "unless separate, medically necessary services are required that cannot be rendered by the surgeon."

Example: The surgeon anticipates that the patient's post-op pain measures will need to be more extensive than usual. The surgeon should request in writing that the pain specialist provide management services. That documentation indicates that the pain management care is separate from anesthesia used during the surgical procedure.

2. Support the Service Rendered

The patient's medical record should include notes regarding four areas:

• Service performed
• Substance injected
• Site of injection
• Dosage of the substance.

Next, document the appropriate diagnosis supporting pain management. For example, the surgeon requests postoperative care for a patient following shoulder surgery.

If the surgeon doesn't document a definitive diagnosis, code according to the patient's signs and/or symptoms, such as 719.41 (Pain in joint; shoulder region).

However, "Once a definitive diagnosis has been reached, you no longer code the symptoms," reminds Judith L. Blaszczyk, RN, CPC, ACS-PM, compliance officer with Auditing for Compliance and Education, Inc. Instead, code according to the reason for surgery, such as a ruptured rotator cuff (338.18, Other acute postoperative pain).

3. Choose Codes for Each Day

The appropriate code for pain management service will depend on each case. A possible code for management following shoulder replacement might be 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement]), for example.

Don't forget: CMS dropped the 10-day global period for 64416 in 2009. That means that if your pain management specialist conducts a follow-up the next day, you can bill an E/M service such as 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient...) for managing the patient's postoperative pain with the continuous infusion catheter.

4. Steer Clear of PCA Filing

If your physician starts patient-controlled anesthesia (PCA) for a patient, be prepared for denials.

"A payer would likely reject codes for starting PCA since the surgeon could render that service," says Tacy Brown, director of billing and compliance with Mountain West Anesthesia in Salt Lake City, Utah.

For example, you would not be able to separately report postoperative pain management services using 62318 (Injection, including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, with or without contrast [for either localization or epidurography], epidural or subarachnoid; cervical or thoracic) or 62319 (... lumbar, sacral [caudal]), depending on the catheter placement.