Anesthesia Coding Alert

Pain management services are still relatively foreign territory to most payers in terms of contracting. This can work for or against a pain practice seeking fair reimbursement. Negotiating an effective pain management contract is one way for pain management practitioners to ethically optimize reimbursement for procedures.

However, the negotiation process can be tricky, with success largely dependent on the knowledge of the individuals negotiating on behalf of the practice. Therefore, becoming conversant in both the clinical and business sides of issues such as medical necessity, treatment protocols, cross walking of diagnoses to treatments, and local medical review policies can be extremely useful.

Until Medicare recognized the new specialty designation code (72), which distinguishes pain management providers into a new utilization group, specialty costs were tracked using the utilization costs of anesthesia the lowest of all the specialties. This method of reimbursement calculation often leads carriers to assign inadequate reimbursement for pain procedures, which can be costly to perform.

Mary Jo Marcely, CPC, senior vice president of NAPA Management Services, an anesthesiology and pain management consulting firm in Syracuse, N.Y., says, "As more and more pain practitioners file for specialty designation, and as Medicare more accurately calculates the costs and utilization of pain management services, reimbursement is expected to increase. Other third-party carriers may eventually follow Medicare's lead. But this is likely to be a slow process. Many private payers lack the systems, resources, budgets, and desire for the detailed internal education as well as policy and procedure research and development needed for the overhaul of existing reimbursement mechanisms."

Marcely cites Aetna as an example where pain management providers can benefit from a pain management contract. "Aetna has adopted several internal policies that restrict pain management providers from getting paid for such services as conscious sedation and IDET, among other procedures. For contracts negotiated prior to April 1, 2002, the anesthesia guidelines with general references to pain management apply. For contracts negotiated after this date, a specific and detailed pain management policy is effective."

Marcely advises every pain practice to evaluate its contracts and to seek potential renegotiation opportunities. "This is especially important for those practices that are still billing under the same tax identification number as the anesthesia group with which they practice. The reason may be that those contracts may have been entered into prior to the formation of the pain practice, or may not have been reviewed with a pain management focus for quite some time. In addition, many times groups that incorporate pain management and anesthesia may compromise pain service reimbursement to gain a better per-unit rate on the anesthesia side," Marcely says.

Note: An excellent resource is the Managed Care Advisor (Contracting and Reimbursement), which is on the Web at www.brownstone.com, or call (800) 643-8095.