Pain management: from 2017 and beyond

Tougher pain management billing regulations, along with more documentation and closer scrutiny by payers are the order of the day following 2017’s many changes. Thanks to claims being flagged for review, physicians who were used to being paid within 30 days are now seeing payments held up as long as 180 days! To be approved for pain management charges, you will need to thoroughly document all evidence for supporting the necessity of the procedures.

With more post-service pre-payment coding reviews as well as moving certain procedures from surgery centers to the provider’s office, physicians who once were reimbursed by past effective procedures are now finding the same type of services and their claims denied.

The Office of Inspector General (OIG) has been paying attention to the following pain management areas:

• Orthotics pricing reviews on back and knee braces as well as LCD compliance
• Transitional Care Management billing will be subject to review for patients transitioning from inpatient to LTAC, nursing, rehab or their own home
• Chronic Care Management review of non-face-to-face billing for patients with at least two significant chronic conditions putting them at risk of death which  are expected to least at least 12 months or until death
• Durable Medical Equipment (DME) payable only to Medicare enrollees
• Additional Prolonged Services will be subject to medical necessity reviews
• Review drug wastage in single-use vials

Some examples of changes since 2017 of many screening and laboratory codes  

Between the 2017 editions of the Medicare Physician fee Schedule (MPFS) and the CPT coding manual, below are listed some changes in pain management billing and coding as well as overall compliance. These include:

• (Non-anesthesia) conversion factor (CF)

Beginning in 2017 this rose slightly from $35.8043 to $35.8887

• Urine drug testing (UDT)

The Final 2017 Clinical Laboratory Fee Schedule (CLFS) adopted an increase in reimbursement following the recommendations of the Proposed Rule for the Four Medicare UDT confirmation codes, below (codes are not adjusted for geographical location.)

• G0480 from $79.95 to $116.85
• G0481 from $123.00 to $159.90
• G0482 from $166.05 to $202.95
• G0483 from $215.25 to $252.15

Each of the above codes would increase the payment rate by almost $37 over the pre-2017 rates. You and your lab director will need to work with together to ensure that the confirmation testing can accommodate the new requirements, otherwise you will be unable to bill for those four new confirmation codes.

In addition, the following codes were deleted and replaced:

Deleted Medicare screening G-codes: G0477, G0478, G0479

Deleted CPT screening codes: 80300, 803010, 80302, 803043, 80304

Replacement screening codes: In 2017, the deleted codes above were replaced by the following codes that apply to all payers:

• 80305 – Direct optical observation; dipsticks, cups, cards, per DOS, bundles validation testing
• 80306 – Instrument-assisted direct optical observation; per DOS, bundles validation testing
• 80307 –  Instrument chemistry analyzers; i.e. per DOS

The CPT manual also re-defines “percutaneous,” “endoscopic” and “open” regarding coding spinal procedures: if a procedure isn’t classified as percutaneous or endoscopic, code 63001 applies to an open procedure.

Compliance considerations and its seven components

The OIG has outlined a seven-point Compliance Program for Individual and Small Group Physician Practices, upon which practices can use to develop their own effective compliance programs, regardless of specialty. These program components include:

• Conducting internal monitoring with periodic audits
• Develop written procedures and standards for compliance  
• Designate a compliance officer or other contact charged with monitoring efforts and enforcement of standards
• Train personnel on practice standards and their procedures
• Enforce disciplinary standards with publicized guidelines
• Keep communications open between practice employees, such as through staff meetings and other means of keeping staff current on regulatory updates
• Appropriately respond to identified offenses  through incident investigations and disclosure to appropriate governmental entities

Writing a compliance policy is most likely to be delayed or ignored, creating communication and enforcement problems among users. It is important to note that compliance policies as written and implemented must not only be current but reflect the actual practices of that group.{{cta(‘916c08d7-4c12-4f4d-9f5b-8d0d4ab1c008′,’justifycenter’)}}

Should you hire a compliance officer?

Even a larger practice with a full billing and coding department and administrator may find that the challenge of ensuring compliance is more than they can handle. Hiring a dedicated compliance officer to help alleviate these issues by developing a plan and communicating to the staff can be a smart move.  A compliance officer’s main job is to develop an action plan for identifying and correcting compliance risks through regular audits and oversee the practice’s compliance with those plans.

Some duties may also include:

• Establish methods, including audits, for risk-assessment and reducing the practice’s vulnerability to abuse and fraud within government programs, while improving efficiency and quality of care and services.
• Reviewing and adjusting the compliance program to meet ongoing changes in the practice’s needs, as well as with government and payer plans.

For practices which are not able to budget for a dedicated compliance officer there is the option to sign up for any of the multiple Medicare carrier, contractor and administrator “listservs.” These services will email practices updated information concerning regulatory changes by region and state, as well as offer national guidance. You’ll gain access to a large network of compliance professionals who can help you stay connected and compliant.

What can a medical billing service do for your compliance rates?

Partnering with an experienced trusted medical billing and practice management company such as M-Scribe, can help you stay compliant with the latest regulatory changes, whether in coding or procedure, regardless of size or specialty. Our processors’ combined experience, dedication and ongoing training ensure that your claims are submitted promptly and accurately, to the correct payer every time, for optimum reimbursement. With an array of add-on services and advisory assistance, M-Scribe can help your practice its full potential.
Contact us at 770-666-0470 or email for more information on how we can help you with all of your medical billing, revenue and practice management concerns.