Pain management is a different medical specialty than other specialties. They face unique challenges due to federal and state regulations. These changes have led to changes in the coding and payer reimbursement policies. This has increased the importance of efficient pain management medical billing as well as coding services. These are some of the reimbursement issues providers face and some tips to increase revenue from pain management practices.

Beckers ASC Review reports that ICD-10 has made pain management difficult for doctors to comply with federal and payer requirements. There are many issues:

  • Before a physician can provide treatment, the payer requires authorization. Only if medical necessity is established and other conservative treatments have failed, a procedure can be approved. To prove medical necessity, comprehensive medical documentation must be provided.
  • Payer rules limit the number of times a physician can perform a procedure.
  • Post-service prepayment code reviews may be required for practices. When claims are raised for review, payments may be delayed up to 180 days.
  • Payers are restricting the types of procedures that can be done in hospitals and shifting certain procedures to practices in order to reduce costs.
  • Prescription of complex and combination drugs is subject to more restrictions. Doctors must prove that the patient is eligible for the prescribed treatment.
  • Although the CDC and the American College of Physicians have released new guidelines, they recommend that alternative non-pharmacologic treatments be used. However, some of these therapies are not covered by payers.
  • Many physicians are being investigated for prescribing pain medication without proper clinical management. There are strict regulations regarding the use of these drugs.

These challenges make it difficult for pain management practitioners to grow their businesses and remain financially viable. These are some ways to help:

  • Understanding payer rules and new codes: Pain management physicians must have a good understanding of payer rules in order to submit accurate claims using the most current ICD-10/CPT codes. CPT 2017 adds pain management codes, and deletes many codes. CPT codes can also be revised.
  • Manage the cost of procedures: Pain management centers should be aware of managing the costs for therapies like epidurals and complex procedures like radiofrequency ablation (RFA) according to the Beckers ASC Review. The difference in costs for a procedure performed in a clinic and a surgery center is something that centers need to be aware of. They can evaluate the cost of the most expensive procedures to determine if the reimbursements are worth it. This will allow them to manage their programs both from a cost and clinical perspective.
  • Variable patient population: Pain management physicians need to focus on expanding their practice by treating patients with workers’ and commercial insurance. Physicians can make significant income from pain procedures. Having a diverse patient base, including patients with commercial health plans, will allow them to remain competitive.
  • Documentation should be accurate and complete. The operative note should include all details of what happened during the patient session. To avoid issues with payer approval, physicians should continue to be educated about the requirements for a properly-documented operational note. They should also be able to insert new procedures into their electronic medical records. There may not be one template that works for all types of services.
  • Learn how you can better negotiate contracts: After they have a better understanding of the costs of various therapies, pain physicians can negotiate better with payers. Understanding the financial market and the complexities of pain management requires a deep understanding of how to negotiate a contract.

This is why it is so important for pain physicians to work with an experienced medical coding firm that has expert AAPC-certified medical coders. These experts are knowledgeable about anatomy and how the doctor performs the procedure. They can assist with documentation accuracy by helping to determine if the operative notes contain the correct information. These companies offer expert medical billing analysis that can help doctors assess their facility’s financial performance, and suggest ways to improve it.

By Vignesh

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