New to Pain Management

Question:

Pain Management is a brand-new service line for our practice, we have 20 Orthopaedic surgeons (one is interventional ortho/pain management).  We just purchased a C-Arm and are using it in the office.  The pain management surgeon was using this at the outpatient surgical facility.  Is there anything specific regarding billing for the C-Arm for place of service 11 (office) that we should be aware of? 

Answer:

KZA recommends that you reach out directly to the specific insurance carriers that you are contracted with regarding coverage and reimbursement of the C-Arm.  Most pain management procedures include the use of C-Arm in the performance of the procedure and therefore, the use of the C-Arm would not be reported in addition. KZA also recommends you check your Medicare Administrative Contractor (MAC) for specific Local Coverage Determinations (LCDs) for any pain management procedures your clinic will be performing. The LCDs provide information regarding the coverage criteria, requirements, and medical necessity for the procedure(s). 

*This response is based on the best information available as of 2/29/24.

APRN Billing Inquiry

Question:

We have an APRN joining our practice, can you please confirm which pain management procedures they are allowed to perform.  Are they allowed to perform all procedures except RFA procedures?

Answer:

The answer to your question will depend on the NP scope of practice for your state so you will need to research this information for your state.  In addition, check provider qualification requirements with your commercial payors and your MAC. The LCDs for Facet Joint Injections Epidural Steroid Injections, and Nerve Blocks for Chronic Pain and Neuropathy list the provider qualifications.

*This response is based on the best information available as of 2/15/24.

E&M with Injections: Two Diagnoses

Question:

When an established patient presents and the physician conducts an evaluation that results in the decision to administer an injection, with documentation of two distinct diagnoses, is it appropriate to report an evaluation and management (E&M) service in conjunction with the injection procedure based solely on the presence of two diagnoses?

Answer:

An evaluation and management service may be reported concurrently with an injection procedure when the criteria for a significant, separately identifiable service are satisfied.

Two answers apply:

1.      Reporting of the E&M service is not recommended when the secondary diagnosis pertains to the same anatomical location or joint that is the target of the injection procedure. In such circumstances, the presence of a secondary diagnosis does not fulfill the "separately identifiable service" requirement as defined by modifier 25.

2.      Reporting of the E&M service with modifier 25 is appropriate when:

a. The secondary diagnosis involves a separate anatomical location distinct from the injection site.

b. The secondary condition requires independent evaluation and management.

E&M With Injection: What If We Want to Code Based on Time?

Question:

We have a recent case where a patient returned with return of pain about five months after a previous injection. The physician evaluates the patient noting no new injury, no changes in his exam findings and decides to re-inject the patient’s knee without additional treatment options discussed. We shared with the physician that the E&M was not separately reportable. The physician asked, ‘what if I code based on time, is it reportable then?” We are unsure if this makes a difference or not. Will you address this question?

Answer:

KZA agrees with your initial recommendation based on the information provided. In terms of your specific question, whether the rules associated with modifier 25 (significant, separate service) vary based on the methodology supporting a level of service, the answer is “no”.

The E&M guidelines address how to select a level of service based on either MDM (Medical Decision Making) or Time. The rules associated with modifier 25 are specific to the E&M meeting the significant separate service rules, not the methodology of E&M code selection. In the scenario provided, the significant separate services rules are not met; report the injection and drugs, as appropriate.

E/M Visit and CPM Services

Question:

Can you bill E/M level 99202-99215 in conjunction with CPM codes (Chronic Pain Management)

Answer:

Yes, Providers can bill both (E/M) visits with the CPM codes. It is important that the documentation supports an E/M visit that is separate from the time and documentation related to the CPM service. The medical record documentation needs to support each service being performed by extracting the E/M documentation from the CPM note, and both the E/M visit. The CPM service should individually demonstrate the time spent and the elements addressed without duplication from the E/M level service.

Time Reporting for E/M Levels

Question:

My physician is billing office visits 99202-99215 based on time only.  Is this best practice?

Answer:

The E/M services 99202-99205 are based on either medical decision making or time.. Practitioners may choose to either bill by time or medical decision making. The practitioner should evaluate each patient encounter to determine which method is more advantageous. If time is used to calculate the E/M service, the total time should include all work associated with the patient encounter on the date of service. KZA recommends that the practitioner document an attestation statement itemizing the time spent on the specific activities for the patient. Example:. “This encounter took 45 minutes of time including taking a history, performing the examination, reviewing the CT scan, reviewing the PCP’s notes, counseling the patient on the conditions treated formulating a plan of care as well as documenting in the EHR.”