# Pain Pump Trial - Billing for Provider Time



## jenniferleepeeler (Feb 3, 2012)

I am banging my head up against a wall trying to figure this out for one of my providers in our pain management office and I could really use some help.  

He has begun to do Pain Pump Trials for our patients and we are trying to figure out how to bill for the time that our provider is spending with the patient.  We have spoken with Medtronics and were informed that we could use cpt 62311 or 62319 depending on if we are placing the cath or not along with any additional codes such as 77003 if need be.  But that we can not bill an E/M unless the patient is being seen for something additional to the injection.

The question the provider keeps asking is how do we report the time he is spending with the patient which could be several hours being the patient could be receiving several injections during a visit?

If anyone who has experience with billing for the Pain Pump Trial has any advise it would be extremly appreciated!!! 

Thank you!!!!!


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## dwaldman (Feb 3, 2012)

http://www.cms.gov/MLNMattersArticles/downloads/MM5972.pdf

Above is link for prolong E/M services. Below is a excert from the NCCI policy manual

https://www.cms.gov/NationalCorrectCodInitEd/


Modifier 25: The CPT Manual defines modifier 25 as a â€œsignificant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other serviceâ€�. Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s).
Modifier 25 may be appended to E&M services reported with minor surgical procedures (global period of 000 or 010 days) or procedures not covered by global surgery rules (global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient.

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AMA CPT Changes 2012

"The placement and use of a catheter to adminster one or more epidural or subarachnoid injections on a single calender day should be reported in the same amnner as if a needle had been used, ie, as a single injection using either 62310 or 62311. Such injections should not be reported with 62318 or 62319. 

Threading a catheter into the epidural space, injecting substances at one or more levels and then removing the catheter should be treated as a single injection (62310, 62311) if the catheter is left in place to deliver substance(s) over a prolonged period (ie, more than a single calender day)either continously or via intermittent bolus, use 62318, 62319 as appropriate.

When reporting 62310-62319, code choice is based on the region at which the needle or catheter entered the body (eg, lumbar). codes 62310-62319 should be reorted only once, when the substance injected spreads or catheter tip insertion moves into another spinal region (eg, 62311 is only reported once for injection or catheter insertion at L3-4 with spread of the substance or placement of the catheter tip to the thoracic region)."

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 AMA CPT Assistant August 2004 page 1
Counseling and/or Coordination of Care 

One of the least understood elements of evaluation and management (E/M) coding is using time as the key factor when selecting the correct level of E/M services. While most E/M patient encounters are coded using the key components of history, physical examination, and medical decision making, the level of service selected for some encounters will best be reflected by using time as the key component. Physicians and other qualified health care professionals who understand this correct use of time will likely see great benefits; but, as in all of CPT coding, rules must be followed: â€œWhen counseling and/or coordination of care constitute more than 50% of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or unit/floor time in the hospital or nursing facility) time may be considered the key or controlling factor to qualify for a particular level of E/M service.â€� 

Time can be used as the key factor with only those E/M codes that include typical times as part of their code descriptors: 99201-99215, 99221-99233, 99241-99245, 99251-99263, 99301- 99313, and 99341-99350. Thus typical times have been included in many, but not all, of the E/M code descriptors. For example, the emergency department services codes (99281-99285) are published without typical times, eliminating the use of time as the key element for selection. 

Next, the physician must learn what time spent performing the service actually counts toward selecting the code level. The specific times in these code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on the actual clinical circumstances. The times included in the CPT nomenclature represent the actual face-to-face time or unit/floor time (or intraservice time) involved in the E/M service. For office and other outpatient services, the face-to-face time is defined as only that time that the physician spends faceto- face with the patient and/or family. This includes the time in which the physician performs such tasks as obtaining a history, performing an examination, and counseling the patient. In the inpatient setting, unit/floor time includes similar time with the patient and/or family but also includes time spent on the patient's unit writing notes, reviewing labs, and discussing the case with nurses and other care team members. Components of the service that are not conducted face-to-face or on the inpatient unit, such as x-rays, telephone calls, review of other lab tests (or other preservice and postservice work), involve additional time not reflected in the time stated but are included in determining the total work value of an E/M service. 

In addition, physicians must know what activities are considered counseling and/or coordination of care. In this context, counseling is not to be confused with psychotherapy, a specific treatment modality for psychological and behavioral disturbances. In fact, a patient receiving psychotherapy may also receive separate counseling related to areas such as laboratory findings, drug reactions, or treatment options. 

The CPT book defines counseling in relation to E/M coding as a discussion with a patient and/or family concerning one or more of the following areas: 


•Diagnostic results, impressions, and/or recommended diagnostic studies
•Prognosis
•Risks and benefits of management (treatment) options
•Instructions for management (treatment) and/or follow-up
•Importance of compliance with chosen management (treatment) options
•Risk factor reduction
•Patient and family education

When these activities and/or coordination of care constitute more than 50% of the physician/ patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility) time may be considered the key or controlling factor to qualify for a particular level of E/M service. This includes time spent with those who have assumed responsibility for the care of the patient or decision making, regardless of whether they are family members (eg, child's parents, foster parents, person acting in locum parentis, legal guardian). 

The documentation requirements when using time with counseling and/or coordination of care are twofold. First, the physician must include a record of total time of the visit as well as the time spent in the specific counseling or coordination of care activities. Secondly, the note should include a summary of the content of the counseling that occurred. Therefore, in order to select the appropriate E/M code, the first question to ask is â€œDid counseling or coordination of care dominate the visit?â€� This is true whether the E/M service involves a new or an established patient visit. If counseling and/or coordination of care did not constitute more than 50% of the face-toface physician/patient encounter in the office or other outpatient setting or floor/unit time in the hospital or nursing facility setting, then the level of service is selected on the basis of the key components (ie, history, examination, and medical decision making). 

If counseling and/or coordination of care did dominate the visit, then the code is selected based on the total time of the face-to-face physician/ patient (and/or caregiver) encounter (or total floor/unit time in the hospital or nursing facility setting). It is important to note that not all codes have typical times (eg, domicilliary care). In such cases, time may not be used to select the code. In selecting time, the physician must have spent a time closest to the code selected. For example, 99214 has a typical time of 25 minutes and 99213 has a typical time of 15 minutes. If the face-to-face office time is 21 minutes, code 99214 would be selected as it is more than half of the time difference. 

Example

An example may be helpful to demonstrate how to report physician services when more than 50% of the face-to-face physician/patient encounter is spent in providing counseling and/or coordination of care. 

Physician A has been treating Mrs Smith for type II diabetes, hypertension, and obesity for several years. Prior to this appointment, blood work was performed to determine the status of her diabetes. The physician takes a problem focused history and physical examination of the patient. A review of labs reveals that despite relatively good compliance with her 1200-calorie diet for the past six months, her hemoglobin A1C has steadily risen. After reviewing the importance of these findings with the patient, they agree to add insulin to her treatment plan. The patient is understandably upset and has multiple questions about the treatment regiment, low carbohydrate diets, and other information she obtained from the Internet. 

After calming the patient, Physician A discusses insulin-dependent diabetes with the patient, reviewing the importance of diet and exercise, proper insulin administration, and the home management of hypoglycemic reactions. The total time Physician A spends with Mrs Smith is 25 minutes, 15 minutes of which is counseling. Although Physician A performed all three of the key components, counseling clearly dominated the service and can be considered the controlling factor. In this example, it would be appropriate to report code 99214 based on the total 25 minutes spent face-to-face by Physician A with Mrs Smith, of which more than half was spent counseling. Of course, Physician A's documentation should indicate both the extent of the counseling he provided at this encounter as well as the total time and the time counseling during the visit.


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