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.

ARNP Billing Inquiry

Question:

We have an ARNP 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 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.”

Shared Visits in the Hospital for Medicare

Question:

I have a question regarding 2023 shared visit rules. I am reviewing an E&M note where I will select the level of E&M based on the MDM being the substantive part and not time. My question: does each provider have to document their individual time if not a factor in the level of E&M I recommend?

Answer:

No, the documentation of time is not required if Time will not be a determining factor in E&M code selection.

CMS has delayed the implementation of Time as driver for defining the substantive part of the shared encounter until January 2024.

The following excerpt is from the Final Rule published in November 2022.

Page 212:
“After consideration of public feedback, we proposed to delay implementation of our definition of the substantive portion as more than half of the total time until January 1, 2024. We continued to believe it is appropriate to define the substantive portion of a split (or shared) service as more than half of the total time, and proposed that this policy will be effective beginning January 1, 2024….”

You may consider working with your providers to start documenting time should CMS move forward with a final implementation of Time as the driver of substantive time in 2024. This would allow them to become familiar with including this in their notes, while informational at this time, if the code is to be selected on the MDM and not time.