Pain Coding. Devona Slater, CHC, CHA, CMCP Auditing for Compliance & Education, Inc. Copyright 2015 ACE Inc.

Transcription

1 Pain Coding Devona Slater, CHC, CHA, CMCP Auditing for Compliance & Education, Inc.

2 Some Background MEDICARE NCD-National Coverage Determination LCD-Local Coverage Determination Both provide coverage information and determine whether services are reasonable and necessary on certain services offered by providers

3 What s the Difference? NCD- Mandated at the national level and all Carriers and Administrative Contractors must follow these guidelines LCD-is mandated at the Administrative Contractor level and only applies to that Administrative Contractor s jurisdiction

4 Both NCDs and LCDs Describe clinical circumstances where a service is considered to be reasonable and necessary. Are intended to be educational tools to assist providers in submitting correct claims for reimbursement

5 Basic Categories of Information Coverage Guidance Indications Limitations Medical necessity Procedure requirements Provider qualifications CPT Codes utilized Diagnosis Codes that support medical necessity Revision History

6 Pain Management Examples Acupuncture for Fibromyalgia Biofeedback Botulinum Toxin Types A & B Category III Codes Chronic Pain Management Controlled Substance Monitoring Endoscopic and Percutaneous Lysis of Epidural Adhesions Epidural and Transforaminal Epidural Injections Facet Joint Injections, Medial Branch Blocks and Facet Joint Radiofrequency Implantable pumps SI Joint Injections and Destruction Spinal Cord Stimulators Peripheral Nerve Blocks..and the list goes on.

7 Policy for Reviewing NCD and LCD There should be a process in your practice for periodically checking to see if new or revised NCD/LCDs have been issued. Many payors have a notification method for e- mailing when policies are changing. Annually you should go through just to make sure that you did not miss any. Annually you should compare the requirements in the LCD to your templates to see that you have prompts for required information.

8 New Coding Changes for 2015 Joint Injections Vertebroplasty & Vertebral Augmentation Myelography New Post-op Pain Codes Stimulator Analysis Drug Screens

9 Joint Injections Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); without ultrasound guidance with ultrasound guidance, with permanent recording and reporting 20605, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance with ultrasound guidance, with permanent recording and reporting 20610, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance with ultrasound guidance, with permanent recording and reporting

10 Joint Injections With & Without Ultrasound

11 Translaminar Epidurals Fluoroscopy Bundled for 2015 Per the 2015 CMS Physician Fee Schedule fluoroscopy now bundled into translaminar epidural procedures Effective 1/1/2015 MEDICARE/GOVERNMENT PAYORS ONLY Impacts the following codes: Interesting note: NCCI bundled fluoro into Epidurals as of 4/1/15 effecting all insurance companies

12 Payments Restored to 2013 Levels Sort of

13 Vertebroplasty ; Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic ; lumbosacral ; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) Moderate sedation for the block is bundled.

14 Vertebroplasty & Vertebral Augmentation ; Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic ; Lumbar ; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) Moderate sedation for the block is bundled.

15 Sacroplasty Sacroplasty codes updated 0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed 0201T, bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed Moderate sedation is included When treating the sacrum, sacral procedures are reported only once per encounter

16 Myelography Injection procedure for myelography and/or computed tomography, lumbar (other than C1-C2 and posterior fossa) Myelography via lumbar injection, including radiological supervision and interpretation; cervical ; thoracic ; lumbosacral ; 2 or more regions (e.g., lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical) Radiology codes not deleted. May still be used with if different provider

17 95972 Stimulator Analysis 2014 Complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intra-operative or subsequent programming, first hour 2015 Complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intra-operative or subsequent programming, up to 1 hour

18 More Changes for Drug Testing

19 Drug Testing What s new? Terminology Drug class lists All new codes

20 Drug Testing Terminology Presumptive- to identify possible use or non-use of drug or drug class Definitive- qualitative or quantitative tests to identify drugs and associated metabolites

21 CPT 2014 Drug Testing List Becomes Drug Alcohol (Ethanol) Amphetamines Barbiturates Benzodiazepines Buprenorphine Cocaine metabolite Heroin metabolite (6- monoacetylmorphine) Methadone Methadone metabolite (EDDP) Methamphetamine Class A List Methaqualone Methylenedioxymethamph etamine (MDMA) Opiates Oxycodone Phencyclidine Propoxyphene Tetrahydrocannabinol (THC) metabolites (marijuana) Tricyclic Antidepressants Deleted: Phenothiazines Copyright ACE, Inc

22 CPT 2015 Adds Drug Class B List Acetaminophen Carisoprodol/ Meprobamate Ethyl Glucuronide Fentanyl Ketamine Meperidine Methylphenidate Nicotine/Cotinine Salicylate Synthetic Cannabinoids Tapentadol Tramadol Zolpidem Not otherwise specified

23 Why the Detailed Lists? New presumptive codes Drug screen, any number of drug classes from Drug Class List A; any number of non-tlc devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation, including instrumented-assisted when performed (e.g., dipsticks, cups, cards, cartridges), per date of service ; single drug class method, by instrumented test systems (e.g., discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay), per date of service

24 Drug Testing New Presumptive Codes Drug screen, presumptive, single drug class from Drug Class List B, by immunoassay (e.g., ELISA) or non-tlc chromatography without mass spectrometry (e.g., GC, HPLC), each procedure Drug screen, any number of drug classes, presumptive, single or multiple drug class method; thin layer chromatography procedure(s) (TLC) (e.g., acid, neutral, alkaloid plate), per date of service ; not otherwise specified presumptive procedure (e.g., TOF, MALDI, LDTD, DESI, DART), each procedure

25 Drug Testing Key questions to ask before coding presumptive drug testing services Which class or classes are you testing? Class A Class B What testing method was used? Is it billable per date of service or per procedure?

26 Drug Testing Definitive Drug Testing Able to identify individual drugs and distinguish between structural isomers New definitive drug testing codes Report with codes Consult the Definitive Drug Class Listing Table in CPT

27 And Then There is CMS!!! Deferred adoption of new CPT codes until able to analyze more information CMS created 28 new G codes to replace deleted 2014 codes Since new codes not adopted, CMS has assigned no RVUs or fees for the new CPT codes

28 And Then There is CMS!!! Why is this a problem? Which codes will MC Advantage, MCD, and commercial payers accept? Some payers have been requiring the G codes G0431, G0434 Aetna-Effective 6/1/2012 Cigna-Effective 8/19/2013 UHC-Effective 1 st quarter 2014 Anthem and some BC/BS have also adopted G codes How will the values be determined?

29 What s Likely to Change in 2016

30 Medicare s Final Fee Schedule 2016 Current Medicare RBRVS $ Proposed 2016 RBRVS $ Increase of $0.3083

31 SCS Proposed Change Proposed to Revise the SCS Time Requirements on SCS Programming Removal of the time requirement for Delete code (each additional 30 minutes)

32 Proposed Code Deletion Delete Code Injection, Anesthesia Agent Spinal Accessory Nerve

33 2016 Proposed Changes New Codes for Paravertebral Block; thoracic Single Injection Second and any additional injections Continuous infusion by catheter Note: All image guidance is included

34 Medicare UDS Proposed Changes Per the July Federal Register Deletion of 20+ G codes that are used for Lab coding Establish only two codes GXXX1 Drug screen, any number of drugs or drug classes, any procedure(s)/methodology(ies), any source(s) per day GXXX2 Drug test(s) (confirmatory and/or definitive, qualitative and quantitative), any number of drugs or drug classes, and any procedure (s)/methodology(ies), any source(s), includes sample validation, per day.

35 Medicare UDS Proposed Changes September Peliminary Memo Considering Presumptive three codes 1. direct optical observation w/o scanner GXXXX ($9.90) 2. direct optical observaiton w scanner GXXXX ($19.79) 3. Instrumented IA and other methods GXXXX ($59.37) Condisdering Definitive four codes drug classes GXXXX ($61.45) drug classes GXXXX ($78.66) drug classes GXXXX ($127.82) or more drug classes GXXXX ($167.14) Current Reimbursement for Definitive is $400-$500 range

36 Hot Issues For Pain Physicians

37 Medical Necessity must be reviewed and tied to the services billed. Copyright 2011 ACE, Inc 37

38 DIAGNOSES PROVE MEDICAL NECESSITY Diagnoses tell a story In pain patients diagnosis will usually change and get more specific with different treatments Diagnoses must be clearly documented or easily inferred Diagnoses must document objective and physical findings to support the medical necessity for the care Keep in mind payer local coverage determinations Copyright 2011 ACE, Inc 38

39 Important to Support Medical Necessity Tying the chief complaint to the physical performed and the radiology studies reviewed to come to the conclusion of what would be medically appropriate for this patient. Explanation of why recommendations for services/procedures and the outcome from those services/procedures. Copyright 2011 ACE, Inc 39

40 Billing Visits With Procedures Was the decision to perform the procedure made at a previous visit? Perform the Sharpie test Cross out anything not related to the procedure. Is what is left separately identifiable and significant? Was the E&M for a problem unrelated to the procedure? Add modifier 25 to E&M code when appropriate Copyright 2011 ACE, Inc 40

41 Incident To Services Physician Office Only Medicare defines incident to services as those services and supplies furnished as an integral, although incidental, part of the physician s personal professional services in the course of diagnosis or treatment of an injury or illness. Services billed as incident to the physician may be performed by auxiliary personnel or non-physician practitioners under the required level of supervision Must be performed under direct physician supervision in order to qualify for incident to (i.e., the physician must be in the office while the service is rendered) Incident to services must represent an expense incurred by the physician or legal entity billing for the services. The record must clearly identify who rendered the service, the supervising physician s physical presence and the medical plan the services are incidental to. All services must be within the scope of practice of the non-physician practitioner as defined by state law. Only NP, CNS,PA or Nurse Midwife can charge EM levels above 99211

42 Anesthesia with Chronic Pain Procedures ASA Statement on Anesthetic Care During Interventional Pain Procedures Minor procedures do not routinely require anesthetic care Epidural steroid injections Epidural blood patch Trigger point injections SI joint injections Bursal injections Occipital nerve block Facet injections Prolonged or painful procedures may require MAC Sympathetic blocks Radiofrequency ablation Discography Percutaneous discectomy Trial spinal stimulator lead insertion Major nerve/plexus blocks may warrant MAC Brachial plexus block Continuous catheter techniques Sciatic nerve block 42

43 Anesthesia with Chronic Pain Procedures ASA Statement on Anesthetic Care During Interventional Pain Procedures Major co-morbidities and mental or psychological impediments to cooperation are examples of conditions dictating anesthetic care for even minor pain procedures in unusual patients. The use of sedation and anesthesia must be balanced with the potential risk of harm from doing pain procedures in a sedated patient especially those undergoing cervical spine procedures Copyright 2011 ACE, Inc 43

44 Physical Therapy Important to know: The qualifications of the individual delivering the physical therapy Whether modalities are supervised or direct one-on-one patient care Key Points Physician notes for the goals of the physical therapy Revaluation and note of improvement in order to continue DME arrangements Braces, TENS units etc Copyright 2011 ACE, Inc 44

45 Narcotic Scripts Laboratory Services Continued Scrutiny on Providers Who Issue Opioids President Obama New Mission Directing CDC to spend 8.5 Million in opioid addiction prevention Risk Stratification Documentation in physician record as to why we are testing this patient today Rationale for referring tests on for confirmation Signed Orders Physician groups who have set up a lab need specific oversight Copyright 2011 ACE, Inc 45

46 Summary Separating billing mistakes from intentional fraud Some coding is controversial, CPT has not kept up with the changes within the specialty When there is no code for a procedure, CPT instructs to use the unlisted code Insurers consistently crossing to another code tends to give providers a false security that they should use that code. Manufactures lead providers down the wrong path for coding and billing for services Remember to always get the entire medical record when doing a review Use coders/auditors that understand pain management Copyright 2011 ACE, Inc 46

47 Questions??? Devona Slater, CHC, CHA, CMCP Auditing for Compliance and Education, Inc Barkley Street, Suite 610 Overland Park, KS