Anesthesia providers distinguish themselves by virtue of their ability to manage all types of pain. While most of their time and energy is focused on the acute pain related to surgical procedures and deliveries, many providers also consider themselves qualified to manage chronic intractable pain. The result can be two very distinct types of practice. Those who work in the operating room and delivery suite take on a diverse and potentially challenging caseload but one in which each case is a distinct and complete experience; once the patient is delivered to the PACU, recovery room or ICU, it is done, and the provider moves on to the next case. Conversely, the management of patients suffering from chronic pain conditions presents a different set of challenges.

First of all, there is normally no expectation that the management of the pain will be a one-shot experience. Chronic pain providers are quintessential diagnosticians, committed to tracking down the source and causes of the patient’s discomfort. Most procedures are part diagnostic and part therapeutic. And while anesthesiologists and anesthetists must review a patient’s chart and history to determine an appropriate anesthesia plan, determining an optimal treatment plan for a chronic pain patient can be far more extensive, requiring a separate and distinct evaluation that must be clearly documented. By accepting responsibility for the management of a chronic pain patient, the chronic pain provider may have ongoing responsibility.

Many providers welcome the challenge of chronic pain and commit themselves to the necessary clinical training. The problem is that their work and responsibilities may not dovetail with that of the rest of the anesthesia providers. While a day or two in the pain clinic may provide some welcome diversity to their practice, a full-time commitment to chronic pain requires an entirely different schedule and commitment. Many a hybrid practice (anesthesia and chronic pain) struggles with issues related to incentive and compensation. It is not uncommon for successful chronic pain providers to ultimately break away and start their own practices.

Is Chronic Pain Profitable?

The effective management of a chronic pain practice is all about the numbers. The revenue potential is determined by two factors: the average yield per patient encounter and the average encounters per clinical day. While the average provider in the operating room is lucky to bill for 6 or 7 hours of clinical time per day, a well-organized and managed pain provider may bill for as many as 9 or 10 hours of care a day. The result is that many chronic pain providers generate considerably more per day than their colleagues in the operating room. This, however, is probably the exception rather than the rule.

What makes a chronic pain practice profitable is the support and infrastructure it enjoys. Many a hospital-based pain practice gets its scheduling, insurance verification and medical support from hospital staff. This type of practice can benefit both (a) the providers who only have to worry about their professional fees, and (b) the facility, which gets facility fees for the procedures performed. It is a delicate balance; and the more independence the providers want, the greater the risks they incur.

What Are the Management Challenges?

Filling a chronic pain practice schedule with paying patients is no small challenge. A successful chronic pain practice must rely on a strong referral base. Providers must build good relationships with orthopedists and other specialists to ensure a consistent supply of patients for whom they can generate value. This may involve unique clinical modalities that they can use to promote their practices. What they don’t want to do is be thought of as technicians simply providing standard epidural spinal injections. Ultimately, it is their diagnostic acumen that should distinguish their practice. While the operating room generates a consistent population of surgical patients, the chronic pain population must be pursued and refined. Too often, new providers start by filling their schedule with unprofitable patients just to be busy. As is true in many things, weaning the Medicaid medical management patients from the schedule for procedural encounters with better insurance can be a huge obstacle over time.

Thus it is that successful practices often find it necessary to hire professional managers whose job is to enhance the profitability of the practice. In other words, to be successful, this line of business requires its own distinct monitoring and management. Anesthesia practices that fail to recognize the unique needs of the chronic pain providers typically experience an irreconcilable rift in the practice. Ultimately, compensation that is well designed for the operating room providers, drives off the most productive chronic pain providers.

Are There Compliance Risks?

The billing of patient evaluations requires the use of evaluation and management (E/M) codes. Every claim that is submitted must be appropriately supported by complete and accurate documentation. Since E/M codes are the most utilized by American providers, they are the most scrutinized by auditors. Upcoding and miscoding can create serious red flags that will trigger payer reviews. From a coding and billing perspective, maximizing a provider’s billable income can be a real challenge.

One aspect of chronic pain billing that can be particularly troublesome is unbundling. While chronic pain providers want to be paid for each of the services they provide, the rules for what codes to include keep changing. It used to be that the use of fluoroscopy was separately billable with most of the common injection procedures, but this is no longer the case. There is now a list of common procedures for which the use of fluoroscopic guidance is bundled.

Chronic pain providers must receive regular guidance relative to their documentation and regular feedback from qualified coding staff. It is also important to understand that payers monitor patterns of code submission. Providers who bill only high-level evaluation codes may be subjecting their entire practice to risk, something that really does not happen when billing for anesthesia alone.

Is It Worth Exploring?

The motto here should always be “buyer beware.” Chronic pain can be profitable and can enhance the relationship between the practice and the facility, but there are many variables and effective management is critical.