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
OBJECTIVES Define our customers Maximize billing strategies Decrease claim denials Discuss financials
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.
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
TIPS TO ENSURE REIMBURSEMENT Correct Documentation Correct diagnosis codes Correct CPT codes Correct Modifiers
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
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)
CPT CODES Trigeminal nerve, any division (ie: infraorbital, supraorbital) 64400 ASA RVU -10 (72.48*) Cervical Plexus 64413 ASA RVU -8 (83.00*) Greater Occipital nerve 64405 ASA RVU -5 (64.37*) *Medicare payment ($ in AZ)
CPT CODES Upper extremities Block Type CPT Code ASA Unit worth (Medicare payment $ in AZ) * SSNB CNB SSNB CNB Brachial Plexus 64415 64416 8 (67.54) 13 (82.15) Brachial Plexus (axillary) 64417 8 (73.95) Other 64450 5 (46.98) Lower extremities Block Type CPT Code ASA Unit worth (Medicare payment $ in AZ) SSNB CNB SSNB CNB Sciatic 64445 64446 7 (74.53) 12 (82.15) Femoral 64447 64448 7 (68.62) 12 (73.95) Lumbar Plexus 64449 12 (87.03) Other 64450 5 (46.98)
CPT CODES Trunk Block Type CPT Code ASA Unit worth (Medicare payment $ in AZ) SSNB CNB SSNB CNB TAP (unilateral) w/ U/S 64486 64487 64.68 76.37 TAP (bilateral) w/ U/S 64488 64489 82.06 92.72 Ilioinguinal/iliohypogastric 64425 8 (96.3) Paravertebral 64520 8 (83.67) Other 64450 5 (81.38 Neuraxial Block Type CPT Code ASA Unit worth (Medicare payment $ in AZ) SSNB CNB SSNB CNB Thoracic/Cervical epidural 62310 62318 9 (112.51) 9 (103.91) Lumbar/Sacral epidural 62311 62319 8 (92.54) 9 (99.97) 8 (92.54) Intrathecal injection 62311
U/S GUIDANCE CPT code (separate billing code) 76942 ($61.76*) Technical (cost required to maintain and store equipment) Professional (physician s application of U/S and interpretation) components of U/S usage. Attach modifier -26 if billing just for professional component Requires documentation of needle placement and image interpretation Attach copy of image to billing sheet or chart w/ identification of sonoanatomy (eg, nerves, muscles, bones, vessels, fascia), needle, spread of LA. *Medicare payment ($ in AZ)
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: 64448-59, 64445-51
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
NEW ACUTE PAIN CONSULTATION CPT codes 99251-99254 (99253 most common) Need to include: indication for consult physician/team requesting consult H/P Assessment Recommendations Medicare payment ($ in AZ) 99251: $49.18 99252: $75.20 99253: $115.51 99254: $168.23
FOLLOW UP VISITS Inpatient: 99231-99233 Medicare payment ($ in AZ) (99232 most common) 99231: $39.50* 99232: $72.33* *Medicare payment ($ in AZ) 99233: $104.36* At home: 99441-99443 99441: $12.85* (may not be worthwhile) (1 = 5-10 min, 2 = 11-20 min, 3 = 21-30 min) Criteria to bill: 1. Phone call initiated by pt/guardian, NOT provider. Pt calls about escalating pain and what to do... 2. 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.
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
REFERENCES Updated Guide to Billing for Regional Anesthesia. Kim. Mariano. 2011 Getting the Best Value for Consumable Supplies in Regional Anestheisa. Swenson, Davis. 2011 https://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf http://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.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. 2014 Relative Value Guide. (2014). Park Ridge: American Society of Anesthesiologists. Kyles, J. (2015). 2015 Anesthesia & Pain Answer Book. Gaithersburg: Decision Health AMA CPT code RVU for medicare (https://ocm.ama-assn.org)