Home Town Health Take the Pain out of Coding Pain Clinics J E NAN C U S TER C P C, C C S, C D I P AH IMA A PPROVED IC D - 1 0 - C M/PC S T RAINER AND A MBASSADOR D IRECTOR OF C ODING H EALTHCARE C ODING AND C ONSULTING SERVICES (HCCS) PENNY R USSELL C C S SD S/O BS C ODING MANAGER H EALTHCARE CODING AND CONSULTING SERVICES (HCCS) TAKING THE PAIN OUT OF 1 C ODING PAIN C LINICS After attending this presentation, attendee will be able to: Understand Key Documentation Requirements for Pain Clinics Identification of Medical Necessity Issues and Pain Clinic Reimbursement Identify Key Decision-Making Process for CPT Coding: Approach, Levels, Locations Understand Coding Source Guidance and Compliance Improve Clinical Documentation and Identify Areas of Opportunity TAKING THE PAIN OUT 2 OF C ODING PAIN C LINICS Coding Check List Coding for hospital encounters for pain clinic injections are based on the documentation provided by the physician The physician must provide the documentation to be able to code accurately with diagnosis and specifically what procedures are performed. The coder will code based on the physician documentation and may not always be what is specifically covered The coder would not query based on payment and would only query based on clarification to be able to code accurately. 3 1
PROCESS TO CODING PAIN MANAGEMENT Know the approach Epidural Transforaminal Facet Know the type of injection Anesthetic Steroid Neurolytic agent 4 Procedures Injections Destruction by Neurolytic Agents Insertion of Intrathecal Catheters & Pump delivery systems Spinal Nerve Stimulators Epidural Neurolysis 5 Key to Coding and Medical Necessity is Physician Documentation The reason for the admission is for pain control or pain management The definitive diagnosis cause of the pain The diagnosis need to support medical necessity and will affect local payer coverage determinations. 6 2
Challenges Denials due to poor documentation LCDs and payor policies, and NCCI edits Facilities that charge procedures vs having coders code procedures Reporting levels of injections correctly Reporting diagnosis correctly due to physician orders and old H&Ps 7 Issues with Coverage Facilities should develop documentation guidelines Physicians/providers to correctly document diagnosis Physicians/providers to correction document the actual medication being injected Check with payers/carriers for LCDs 8 Local Coverage Determination and Medical Necessity Polices are being updated more frequently Diagnosis driven Frequency of injections The progress of treatments 9 3
Medical Necessity Payors are requiring more documentation to support medical necessity Example of payor policy requirements to support 3-6 month of conservative treatment Specific percentages of pain relief Prior physical therapy Medication therapy MRI findings- this is sometimes difficult to get approved 10 NCCI Edits and Considerations What is the facilities policy NCCI or not Know your carries code Worker s compensation 11 Documentation Challenges with Injection Levels Accurate provider documentation Specific number of nerves or disc levels Without the specific documentation, it will lead to incorrect coding and billing 12 4
Coding Rules and Guidelines 13 Question: Diagnosis Coding A patient is diagnosed with lumbar stenosis at L3-4 and L4-5 with severe neurogenic claudication. How should this diagnosis be coded? 14 Answer: Diagnosis Coding Code M48.062 -Spinal stenosis, lumbar region with neurogenic claudication Source: ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2017 Pages: 18-19 Effective with discharges: October 1, 2017 15 5
Question: CPT Coding 64491- Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level 64492- Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) Is it appropriate to report 64491 and 64492 together? 16 Answer: CPT Coding Yes, 64492 is appropriate with 64491 Source: CPT Assistant, October 2012 Page: 15 17 Question: CPT Coding What CPT codes are appropriate when lumber medial branch blocks were documented on the right L3, L4, and L5? 18 6
Answer: CPT Coding Code 64493 Code 64494 Source: CPT Assistant, August 2010 Page: 12 19 Facet Joint Instructions and Modifier -50 Use The modifier 50 is defined as a bilateral procedure Understanding anatomy of the joints 20 Facet Joint Instructions and Modifier -50 Use, continued. Decision Making: Is the facet joint injection performed on the right and left side of the joint level? If yes, modifier should be applied Source: Coding Clinic for HCPCS Fourth Quarter 2009 Page: 10 21 7
Test Yourself Question #1 What are the appropriate code assignment when patient receives 3 separate nerve blocks into the same lateral branch nerve? 22 Question #1 Answer CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch, would be appropriately reported only once in this case since all 3 nerve blocks were administered to the same nerve or branch. 23 Test Yourself Question #2 A patient was seen at the facility and underwent a left-sided L5 and S1, S2, S3 and S4 lateral branch nerve block for diagnostic purpose with C-arm fluoroscopy. What are the correct codes for lateral nerve block? 24 8
Question #2 Answer Based on the operative report a medial branch nerve block was performed at the L5 and a lateral branch nerve block was performed at the S1, S2, S3 and S4. Therefore, it would be appropriate to report CPT code 64493, Injections, diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT) lumbar or sacral, single level, for the L5 medial branch block. For the 4 lateral branch block injections at S1, S2, S3, and S4, report 4 units of CPT code 64450, Injections, anesthetic agent; other peripheral nerve or branch. 25 Neurostimulators What they are Reason for placement Determine if temporary vs permanent Know what are they placing- generator with leads vs leads Is it being replaced? Are leads being placed percutaneous or incisional? 26 Neurostimulators: Permanent vs. Temporary There can be confusion with permanent vs temporary neurostimulator insertions. The process is, the physician will place a trial (temporary). The trial is to see if it controls the pain. If the patient has success they will come back in for the permanent neurostimulator. Sometimes the physician will use the same lead to connect to the generator. 27 9
Question: CPT Coding Can CPT Codes 64581 and 64590 be reported for placement of the permanent neurostimulator electrode array and implantation of the pulse generator? 64581 - Incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve); sacral nerve (transforaminal placement) 64590 - Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive couplin 28 Answer It would be appropriate to code 64590 and 64581 Where can these types of procedures be performed CPT Code book does not distinguish timeframes for code reporting Source: CPT Assistant, December 2012 Page: 14 29 Device Codes with Neurostimulators There is device codes with Neurostimulators. Device HCPCS codes are supply codes of the implant. These are captured by the facility on what the physician performs and normally not coded by the coder. This is why it is important to code the procedures correctly because the device codes are the implants associated with what was performed. 30 10
Insertion of Removal of Intrathecal Catheters/Pumps These procedures are performed to allow medication to be infused via subcutaneous reservoir for (cancer, chemotherapy, and pain management drugs). It is important to know how it is being placed and if it is removed. The physician will sometimes place the catheter and other times will place catheter with a pump/reservoir. The physician may also perform with a Laminectomy. We will also need to know if the pump is inserted, is it non-programmable or programmable with electronic analysis. 31 Coding Insertion of Intrathecal Catheter with Pump A patient is coming in to have a intrathecal catheter placed with pump due to chronic low back pain. The codes reported would be CPT-62350 & 62362. We would use the CPT-62350 without laminectomy. The physician would have to document it was performed via laminectomy. 32 Parting Reminders It is important for facilities to communicate with physicians and provided education on documentation and compliance. - Coders play a large role in feedback Query physicians for clarification and not based on payment. 33 11
Value Learning Outcomes On Conclusion of this In-Service you should be able to successfully: Understand Key Documentation Requirements for Pain Clinics Identification of Medical Necessity Issues and Pain Clinics Reimbursement Identify Key Decision Making Process for CPT Coding: Approach, Levels, Locations Understand Coding Source Guidance and Compliance Improve Clinical Documentation and Identify Areas of Opportunity 34 References CPT Assistant Coding Clinic ICD-10-CM Official Guidelines for Coding and Reporting CPT 2018 https://www.cms.gov/medicare/medicare- Contracting/ContractorLearningResources/downloads/ja65 26.pdf 35 Quality THANK YOU FOR YOUR TIME We welcome all questions! jcuster@hccscoding.com prussell@hccscoding.com 36 12