BILLING FOR A PEDIATRIC PAIN SERVICE

Transcription

1 BILLING FOR A PEDIATRIC PAIN SERVICE J O N A T H A N J E R M A N, M D M E D I C A L D I R E C T O R P H O E N I X C H I L D R E N S H O S P I T A L P A I N P R O G R A M V A L L E Y A N E S T H E S I O L O G Y P E D I A T R I C P A I N P R O V I D E R S

2 OBJECTIVES Define our customers Maximize billing strategies Decrease claim denials Discuss financials

3 CUSTOMERS 1. Patients Superior analgesia, potential avoidance of SE from other analgesics. 2. Surgeons Increased patient satisfaction, shorter hospitalizations, better pain control. 3. Hospitals Increased patient satisfaction. Literature shows that PNBs shorten LOS in PACU and on hospital wards. Overall benefit of pain service to the hospital and its providers. 4. Insurance providers improved care, shorter LOS, etc.

4 CHARGE VS COLLECTION Ideally: collections approximates charges Become familiar with the insurance demographics of your patients. Pick top (high volume) payors Pick low (low volume) payors The great negotiator

5 TIPS TO ENSURE REIMBURSEMENT Correct Documentation Correct diagnosis codes Correct CPT codes Correct Modifiers

6 DOCUMENTATION Surgeon Request On anesthesia record Type of block/catheter On anesthesia record Ultrasound Proper annotation Store in patient s chart or keep available for billing audits

7 DIAGNOSIS CODES ICD-10 Primary code: G89.18 (other acute post-operative pain) Secondary code: specific to site of pain (ie: shoulder pain M25.519)

8 CPT CODES Trigeminal nerve, any division (ie: infraorbital, supraorbital) ASA RVU -10 (72.48*) Cervical Plexus ASA RVU -8 (83.00*) Greater Occipital nerve ASA RVU -5 (64.37*) *Medicare payment ($ in AZ)

9 CPT CODES Upper extremities Block Type CPT Code ASA Unit worth (Medicare payment $ in AZ) * SSNB CNB SSNB CNB Brachial Plexus (67.54) 13 (82.15) Brachial Plexus (axillary) (73.95) Other (46.98) Lower extremities Block Type CPT Code ASA Unit worth (Medicare payment $ in AZ) SSNB CNB SSNB CNB Sciatic (74.53) 12 (82.15) Femoral (68.62) 12 (73.95) Lumbar Plexus (87.03) Other (46.98)

10 CPT CODES Trunk Block Type CPT Code ASA Unit worth (Medicare payment $ in AZ) SSNB CNB SSNB CNB TAP (unilateral) w/ U/S TAP (bilateral) w/ U/S Ilioinguinal/iliohypogastric (96.3) Paravertebral (83.67) Other (81.38 Neuraxial Block Type CPT Code ASA Unit worth (Medicare payment $ in AZ) SSNB CNB SSNB CNB Thoracic/Cervical epidural (112.51) 9 (103.91) Lumbar/Sacral epidural (92.54) 9 (99.97) 8 (92.54) Intrathecal injection 62311

11 U/S GUIDANCE CPT code (separate billing code) ($61.76*) Technical (cost required to maintain and store equipment) Professional (physician s application of U/S and interpretation) components of U/S usage. Attach modifier -26 if billing just for professional component Requires documentation of needle placement and image interpretation Attach copy of image to billing sheet or chart w/ identification of sonoanatomy (eg, nerves, muscles, bones, vessels, fascia), needle, spread of LA. *Medicare payment ($ in AZ)

12 CHARGE MODIFIERS - 59 Post operative pain - 50 Bilateral blocks - 51 Multiple blocks, same extremity. Subsequent block is reimbursed 50% but denial claims significantly reduced Example Femoral CNB and sciatic SSI for a ACL repair with auto graft would be: ,

13 POST-OPERATIVE: DOCUMENTATION REQUIREMENTS 7 Components are used to determine the level of service. History Examination Medical Decision Making Counseling Coordination of Care Nature of presenting problem Time

14 NEW ACUTE PAIN CONSULTATION CPT codes (99253 most common) Need to include: indication for consult physician/team requesting consult H/P Assessment Recommendations Medicare payment ($ in AZ) 99251: $ : $ : $ : $168.23

15 FOLLOW UP VISITS Inpatient: Medicare payment ($ in AZ) (99232 most common) 99231: $39.50* 99232: $72.33* *Medicare payment ($ in AZ) 99233: $104.36* At home: : $12.85* (may not be worthwhile) (1 = 5-10 min, 2 = min, 3 = min) Criteria to bill: 1. Phone call initiated by pt/guardian, NOT provider. Pt calls about escalating pain and what to do Related evaluation/management (E/M) service has not occurred in previous 7 days ie: pt transitions from IP to OP management of CPNB 3. Phone conversation does not lead to face-to-face visit w/in next 24 hrs.

16 COST/BENEFIT TO RUN PAIN SERVICE Consultations/progress notes: Collection rate (Arizona across payor mix) Productivity PCH/Valley 5 pain physicians 17% higher productivity in terms of billing (pain + anesthesia) 25 general anesthesiologists Hospital support: Trauma (level 1 trauma with in-house anesthesiologist) Pain stipend (patient satisfaction) Physician extenders Multidisciplinary pain clinic model MD/PT/Psychology/NP

17 REFERENCES Updated Guide to Billing for Regional Anesthesia. Kim. Mariano Getting the Best Value for Consumable Supplies in Regional Anestheisa. Swenson, Davis Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf Network-MLN/MLNProducts/downloads/GloballSurgery-ICN pdf Abraham, M. (2015). Current procedural terminology: CPT : 2015 (Professional ed.). American Medical Association ICD-9-CM: International classification of diseases, 9th revision ; clinical modificaiton, sixth edition, color coded, 2015 (2015 Physician ed., Vol. 1&2). (2014). Los Angeles, Calif.: PMIC Relative Value Guide. (2014). Park Ridge: American Society of Anesthesiologists. Kyles, J. (2015) Anesthesia & Pain Answer Book. Gaithersburg: Decision Health AMA CPT code RVU for medicare (