Laxmaiah Manchikanti
Multiple issues related to documentation, billing, and coding are facts of life for physicians practicing interventional pain management. Emphasis continues on the description and definition of what the physician does for and to the patient. Various issues related to billing and coding in interventional pain management requires understanding of procedural coding systems, diagnostic coding systems, and appropriate documentation for interventional techniques and other services provided by physicians. Consequently, documentation of medical services is necessary to provide information, which is medically necessary and indicated, to assist health care professionals in providing services to patients. Furthermore, appropriate documentation, billing, and coding also reflect the competence and character of the physician while assisting in the financial survival.
DIAGNOSTIC CODING SYSTEMS
The medical necessity for any physician or provider encounter requires appropriate diagnosis and coding by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to justify services rendered and to indicate the severity of a patient’s condition.1,2 Coding should be completed to the highest degree of certainty for each encounter. Coding also should correlate with multiple components of a patient’s medical record, including initial evaluation or follow-up visits and the billing statement.
The ICD-9-CM is a coding system used to report patient illnesses, injuries, complaints, or symptoms, termed diagnoses.2 The ICD-9-CM communicates to third-party payers—the need for medical services or why a physician performed a service. The ICD-9-CM system consists of code numbers and narrative descriptions similar to those found in the Current Procedural Terminology (CPT), even though the two systems are distinctly separate and different.
In addition to the ICD-9-CM diagnostic coding systems, other diagnostic coding systems are also available. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), for psychiatric and mental health services is one such system.3 The International Association for the Study of Pain (IASP) also has published a diagnostic classification of pain disorders, a coding system entirely different from the ICD-9-CM and the DSM-IV.4
Subsequent to ICD-9, ICD-10, the 10th revision has been introduced for coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as classified by the World Health Organization (WHO).5 While the United States is considering its application, approximately 25 countries already use ICD-10 for reimbursement and resource allocation in their health systems. The United States will begin official use of ICD-10 on October 1, 2013, using clinical modification of ICD-10-CM for diagnosis coding and procedure coding and ICD-10-PCS for inpatient hospital procedure coding.5
PROCEDURAL CODING SYSTEMS
Procedural coding systems communicate the procedures and services provided to patients and the reasons they were provided. It is required for physicians to understand procedural coding systems not only for proper reimbursement and for appropriate record keeping, but also to avoid fraud and abuse implications. The advent of the Medicare resource–based relative value scale (RVS) replacing the long existing usual, reasonable, customary charge; impact of fraud and abuse regulations on medical practices; and, the economic impact of improper coding and the positive results of accurate documentation and coding have made it mandatory for providers to understand procedural coding systems, along with diagnostic coding systems.6 Procedural coding systems consist of CPT, ICD-9, and Healthcare Common Procedure Coding System (HCPCS).1,2,6-10
MEDICAL NECESSITY
Medical necessity requires appropriate diagnosis and coding by the ICD-9-CM to justify services rendered and indicates the severity of a patient’s condition.11 The Balanced Budget Act (BBA) (HR 2015, Section 4317) requires all physicians to provide diagnostic information for all Medicare/Medicaid patients starting from January 1, 1998.12,13 Physicians are required to code by listing the ICD-9-CM diagnostic codes shown in the medical record to be chiefly responsible or the services provided. Coding should be to the highest degree of certainty for each encounter. Medical necessity is defined in numerous ways:
In accordance with generally accepted standards of medical practice.
Clinically appropriate in terms of type, frequency, extent, site, and duration.
Not primarily for the convenience of the patient, physician, or other healthcare provider.”
WIDE ARENA OF DOCUMENTATION
Federal, state, third party payor, and managed care plans rely heavily on provider documentation when assessing the claims for various parameters. These include the following:
Medical Record
A medical record is a document with confidential information that functions as a clinical record and a business record. The medical record (Table 13-1) facilitates various functions:9,16-19
TABLE 13-1. Functions and Requirements of Patient’s Medical Record
The typical information for an interventional pain management medical chart (electronic and/or hard copy) is as follows:
Medical insurance card copy
Patient’s driver license copy
Patient guarantee and authorization forms
Advanced beneficiary note
Radiographic evaluation results
Results of various medical tests
Facility notes
Consultation reports
Correspondence
Documentation Process
A multitude of personnel associated with a practice or a facility are responsible for documentation. They include physician assistants, nurse practitioners, clinical nurse specialists, physical therapists, psychologists, nurses, and medical assistants who obtain patient histories and vital signs, administer injections, and otherwise provide certain restricted services.
To meet the entire documentation criteria, the following checklist must be utilized:
Support the medical necessity of the service performed.
Provide a clear description of the procedure or service including technique and end results.
Make it clear that the procedure was performed by the reporting or billing physician.
Document appropriate and specific diagnostic code as ICD-9-CM diagnostic code.
Provide documentation of indications and medical necessity, which may be reviewed by payors at any time.
Follow correct coding initiatives (CCIs) and Local Coverage Determinations (LCDs) with the limitations, which become part of documentation.
Electronic Documentation
The evolution of medical records from paper to electronic changes the work processes for seeing a patient for storing information, for accessing information, and the look of the output when the note is printed. However, using electronic health records or electronic medical records does not change the duty to comply with the basic medical record guidelines. Some of the issues such as legibility, storage in one place, locking the records in the office at night, and off-site access become nonissues.
Types of Documentation
Documentation includes evaluation and management services and interventional techniques. Documentation for interventional techniques may vary based on whether the procedure was performed in a facility setting such as hospital outpatient department or ambulatory surgery center (ASC) versus in a physician’s office.
DOCUMENTATION OF INTERVENTIONAL PROCEDURES
All interventional techniques are considered surgical procedures. Documentation requirements are as follows:
Multiple developments in evolution of interventional pain management include changes in CPT 2000 to 20117,8,11,12; the final rules for 2011 on physician payment policies; the Medicare program prospective payment system for hospital outpatient services and ASCs; and ongoing development of CCIs, affecting almost all interventional techniques.
Issues of correct coding and medical necessity and guidelines with regards to effectiveness and frequency and number of interventions, combination of blocks/interventions, and number of interventions per setting continue to remain contentious.20-24 Further, enactment of the Affordable Care Act (ACA)25 also is responsible for significant changes in not only billing, coding, etc, but the entire practice of medicine.
CORRECT CODING POLICIES
A multitude of codes reflect the wide spectrum of services provided by various medical providers, and many medical services can be rendered by different methods and combinations of various procedures. Hence, multiple codes describing similar services are frequently necessary to accurately reflect the particular service a physician performs. However, when multiple procedures are performed at the same session, the procedure and postprocedure work do not have to be repeated for each procedure; and, therefore, a comprehensive code describing the multiple services commonly performed together can be used. Many activities which are integral to a procedure are considered as generic activities and are assumed to be included as acceptable medical/surgical practice and, while they could be performed separately, they should not be considered as such when a code narrative is defined. Hence, all services integral to accomplishing a procedure will be considered to be included in that procedure and, therefore, will be considered a component and part of the comprehensive code.
Standards of Medical/Surgical Practice
Many of the provider activities during a procedure are integral to a procedure and termed as generic activities, which are assumed to be included as acceptable medical/surgical practice, considered to be included in that procedure and therefore considered a component of the procedure. Some generic services integral to standard medical/surgical services include many of the components as illustrated inTable 13-2.
TABLE 13-2. Multiple Generic Services Integral to Standard Medical/Surgical Services.
Cleansing, shaving, and prepping of the skin
Draping of the patient
Positioning of the patient
Insertion of intravenous access
Administration of sedation
Local, topical, or regional anesthetic administration
Identification of the surgical approach
Surgical cultures
Wound irrigation
Insertion and removal of drains, suction devices, dressings,
and pumps. Application, management, and removal of
postoperative dressings, including transcutaneous electrical
nerve stimulation units and institution of patient-controlled
analgesia
Preoperative, intraoperative, and postoperative
documentation
Surgical supplies, unless accepted by existing CMS policy
Further, intravenous access, cardiopulmonary monitoring, and anesthesia by a physician, and conscious sedation are considered as included in the medical/surgical package. A majority of invasive procedures require the availability of vascular and/or airway access, cardiopulmonary monitoring, anesthesia by physician, and conscious sedation. Thus, these are already included in the value of the comprehensive procedure as a part of medical/surgical package.
In addition, evaluation and management services with a procedure are considered as an integral part of a comprehensive procedure.
Add-On Codes
The CPT coding system identifies certain codes that are submitted with other codes. These codes are identified generally with a statement such as, “List separately in addition to code for primary procedure” in parentheses. The supplemental code is to be used only with certain primary codes that are identified in parentheses. The purpose of these CPT codes is to enable providers to separately identify a service that is performed in certain situations as an additional service.
Add-on codes relevant to interventional pain management are subsequent transforaminal epidural injections (CPT codes 64480 and 64484), facet joint blocks (CPT codes 64491, 64492, 64494, and 64495), and facet joint neurolysis (CPT codes 64623 and 64627).
Modifiers
In order to expand the information provided by the five-digit CPT codes, a number of modifiers have been created by the AMA, CMS, and local Medicare carriers. These modifiers, in the form of two digits, either numbers, letters, or a combination of each, are intended to convey specific information regarding the procedure or service to which they are appended. Modifiers are attached to the end of a code to indicate that a service or procedure described in the code definition has been modified by some circumstance. However, explicit understanding of the purpose of each modifier is required prior to its usage.
Family of Codes
The CPT manual describes certain codes that include two or more component codes that should not be reported separately, as these are considered members of a code family and included in the more comprehensive code. As such, comprehensive codes include certain services that are separately identified by other component codes. Although, component codes as members of the comprehensive code family represent parts of the procedure, they should not be listed separately when the complete procedure is performed; the component codes are considered individually only if the procedures they describe are performed independently of the complete procedure. If this is not the case, all services listed in the comprehensive codes are considered to make up the total service.
Unlisted Services or Procedures
Multiple sections in the CPT manual list certain codes that end in “99” or “9,” in a few cases used to report a service that is not described in any code listed elsewhere in the CPT manual.
Mutually exclusive codes are codes for procedures that cannot reasonably be performed in the same session.
Medically Unlikely Edits
CMS implemented Medically Unlikely Edits (MUE) January 1, 2007, as another means to reduce improper payments due to reporting errors on claims. CMS gives this definition of an MUE: “An MUE for an HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.” Not every code has an MUE and CMS does not publish every MUE.
Incorrect Coding
Incorrect coding is defined as the intentional or unintentional billing of multiple procedure codes for a group of procedures that are covered by a single comprehensive code. Incorrect coding includes both unbundling and upcoding. Various types of incorrect coding examples include:
References