Health Information Management

Soothe the sting of pain management coding by taking note of key details in the operative report

JustCoding News: Outpatient, May 19, 2010

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The controversial trial of Jack Kevorkian, MD, in the 90s was a strong influence that contributed to the rise of the pain management specialty, according to Stephanie Ellis, RN, CPC, owner and president of Ellis Medical Consulting, Inc., in Brentwood, TN.

Patients with terrible, chronic pain hired Kevorkian to end their suffering with lethal doses of medication. Kevorkian’s actions were extreme and he went to jail for them, but his methods brought these cases to the forefront. In a way, he inspired today’s pain management specialists to provide non-lethal treatment to patients suffering from terrible pain.

Today physicians perform a number of pain management procedures, however coding for these services can be difficult, said Ellis, who spoke during HCPro’s April 14 audio conference, “Pain Management Coding: Strategies to Ensure Compliance and Reduce Denials.” The Office of Inspector General (OIG) is focusing on the medical necessity of certain pain management procedures (e.g., transforaminal epidural steroid injections [TESI]), which means coders must pay close attention to clinical documentation before assigning pain management codes.

Coding ESI and TESI procedures

Physicians perform epidural steroid injections (ESI) for pain relief or for diagnostic purposes, Ellis said. They relieve nerve root irritation from chronic long-term conditions (e.g., radiculopathy, sciatica, herniated discs, and post-laminectomy syndrome). Physicians typically perform ESI procedures (CPT codes 62310–62319) at one level of the spine, but often fail to document whether they performed the procedure on the left or right side, Ellis said.

TESIs (CPT codes 64479–64484) are more difficult for physicians to perform because of the procedure’s close proximity to the nerve root, the vertebral artery, and the spinal cord, Ellis said.

Physicians generally use fluoroscopic guidance when performing ESIs and TESIs, which are unilateral procedures. When physicians perform a TESI bilaterally, append modifier
-50 (bilateral procedure) or use the -RT or -LT modifiers, depending on the payer’s requirements. The fluoroscopic guidance is separately billable, as long as the payer will reimburse for that charge, Ellis said.

When a physician performs an ESI and a TESI at the same spinal level, you can’t bill both procedures because of unbundling edits. When a physician performs a TESI at the L4-L5 interspace and an ESI at L5, providers should only bill ESI code 62311 for Medicare and other payers who observe National Correct Coding Initiative unbundling edits.

However, when a physician performs an ESI (code 62311) at a different level from a TESI, bill the TESI code with modifier -59 (distinct procedural service). For example, when a physician performs a TESI at the L3-L4 interspace (code 64483) and an ESI at L5 (code 62311), providers should bill code 62311 and code 64483-59.

Be sure to read the documentation closely. When physicians insert the injections into the interspace between the discs, the physicians typically list the spinal levels in a range (e.g., L4-5), Ellis said. In that case, only code for one injection.

Meeting documentation requirements

The OIG’s fiscal year 2010 Work Plan states that the number of TESI procedures rose 130% between 2003 and 2007. In light of that significant jump, the OIG plans to make sure TESI services are reasonable and documentation meets medical necessity requirements.

Medicare will only cover services that are “used to diagnose or treat illness or improve the functioning of a malformed body part,” according to the Social Security Act, § 1862 (a)(10(A).

To avoid scrutiny, physicians must document patients’ improvement as a result of the injection procedure(s). Physicians should also thoroughly document the condition for which the patient is receiving the pain management treatment, Ellis said.

Appropriate documentation of pain management procedures will likely become a RAC audit issue, Ellis said. Before coding pain management procedures, read the entire operative report, and make sure the documentation captures all of the services that the physician performed.

Consider the following tips to avoid documentation practices that could potentially put providers at risk for government scrutiny:

Never bill a procedure based solely on a summary. Don’t code from a surgery schedule. Medicare requires that providers only bill for procedures that physicians document in the body of an operative report. Look beyond the summary section at the beginning of the operative report, Ellis said.

Beware of “canned” operative reports. Sometimes with surgical procedures, physicians use canned operative reports instead of creating an operative report that is tailored to each specific patient and procedure. Canned operative reports do not always contain all the information necessary for proper documentation (e.g., pre- or post-operative diagnosis or language with details about any complications that arise during the procedure). Sometimes the report may not list the procedure the physician performed or indicate upon which side the procedure was performed. Canned operative reports may be time-saving tools for physicians, but they are neither an advisable nor an acceptable method for documenting procedures, Ellis said

Make sure physicians properly correct errors in the medical record. Physicians should never use correction fluid on records or scratch words out. Physicians should make a single line through the error with ink, write the word “error” above it, make the correction, and initial it, Ellis said.

Verify codes physicians list on operative reports. When physicians list codes on operative reports, your job is not finished, Ellis said. You still need to examine the entire report and be sure the codes accurately reflect the services the physician provided and that the physician properly documented the procedures.

Editor’s note: To learn more about how to code for facet joint injections and other pain management procedures, purchase a copy of HCPro’s audio conference “Pain Management Coding: Strategies to Ensure Compliance and Reduce Denials.” E-mail questions to Managing Editor Doreen V. Bentley, CPC-A, at

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