New to Pain Management

Question:

Pain Management is a brand-new service line for our practice, we have 20 Orthopaedic surgeons (one is interventional ortho/pain management).  We just purchased a C-Arm and are using it in the office.  The pain management surgeon was using this at the outpatient surgical facility.  Is there anything specific regarding billing for the C-Arm for place of service 11 (office) that we should be aware of? 

Answer:

KZA recommends that you reach out directly to the specific insurance carriers that you are contracted with regarding coverage and reimbursement of the C-Arm.  Most pain management procedures include the use of C-Arm in the performance of the procedure and therefore, the use of the C-Arm would not be reported in addition. KZA also recommends you check your Medicare Administrative Contractor (MAC) for specific Local Coverage Determinations (LCDs) for any pain management procedures your clinic will be performing. The LCDs provide information regarding the coverage criteria, requirements, and medical necessity for the procedure(s). 

*This response is based on the best information available as of 2/29/24.

ARNP Billing Inquiry

Question:

We have an ARNP joining our practice, can you please confirm which pain management procedures they are allowed to perform.  Are they allowed to perform all procedures except RFA procedures?

Answer:

The answer to your question will depend on the NP scope of practice for your state so you will need to research this information for your state.  In addition, check provider qualification requirements with your commercial payors and your MAC. The LCDs for Facet Joint Injections Epidural Steroid Injections, and Nerve Blocks for Chronic Pain and Neuropathy list the provider qualifications.

*This response is based on the best information available as of 2/15/24.

E/M Visit and CPM Services

Question:

Can you bill E/M level 99202-99215 in conjunction with CPM codes (Chronic Pain Management)

Answer:

Yes, Providers can bill both (E/M) visits with the CPM codes. It is important that the documentation supports an E/M visit that is separate from the time and documentation related to the CPM service. The medical record documentation needs to support each service being performed by extracting the E/M documentation from the CPM note, and both the E/M visit. The CPM service should individually demonstrate the time spent and the elements addressed without duplication from the E/M level service.

Time Reporting for E/M Levels

Question:

My physician is billing office visits 99202-99215 based on time only.  Is this best practice?

Answer:

The E/M services 99202-99205 are based on either medical decision making or time.. Practitioners may choose to either bill by time or medical decision making. The practitioner should evaluate each patient encounter to determine which method is more advantageous. If time is used to calculate the E/M service, the total time should include all work associated with the patient encounter on the date of service. KZA recommends that the practitioner document an attestation statement itemizing the time spent on the specific activities for the patient. Example:. “This encounter took 45 minutes of time including taking a history, performing the examination, reviewing the CT scan, reviewing the PCP’s notes, counseling the patient on the conditions treated formulating a plan of care as well as documenting in the EHR.”

Shared Visits in the Hospital for Medicare

Question:

I have a question regarding 2023 shared visit rules. I am reviewing an E&M note where I will select the level of E&M based on the MDM being the substantive part and not time. My question: does each provider have to document their individual time if not a factor in the level of E&M I recommend?

Answer:

No, the documentation of time is not required if Time will not be a determining factor in E&M code selection.

CMS has delayed the implementation of Time as driver for defining the substantive part of the shared encounter until January 2024.

The following excerpt is from the Final Rule published in November 2022.

Page 212:
“After consideration of public feedback, we proposed to delay implementation of our definition of the substantive portion as more than half of the total time until January 1, 2024. We continued to believe it is appropriate to define the substantive portion of a split (or shared) service as more than half of the total time, and proposed that this policy will be effective beginning January 1, 2024….”

You may consider working with your providers to start documenting time should CMS move forward with a final implementation of Time as the driver of substantive time in 2024. This would allow them to become familiar with including this in their notes, while informational at this time, if the code is to be selected on the MDM and not time.

E/M Coding Based on Time

Question:

Our physicians’ defaults to time for almost every office encounter. We are working with them on documentation and what work contributes to total time and what does not. They perform their own independent interpretation of X-Rays (we bill globally) and performs procedures such as for example a shoulder injection or a genicular nerve injection in the office. They are counting the total time spent with the patient, including these activities and we do not believe that is correct. Can you help?

Answer:

Thank you for your inquiry. We will not address the default to time for almost every encounter other than to say medical necessity must be present for time spent. With that said, the activities you identify, because they are billable services represented by other CPT codes (aka are separately reported), do not contribute to the total time spent; this time must be deducted from the total time, assuming the E/M service is reportable.