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Anesthesia Coding Alert

Pain Management Focus:

Preauthorize Your Way to Prompt Payment

Published on Sat Jan 01, 2005

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Coders who focus solely on anesthesia claims occasionally need to get preauthorization for procedures - but pain management coders don't get off as easy and are required to obtain preauthorization almost every day. If you continually fight the preauthorization battle, fill your arsenal with some tried-and-true tips provided by pain management coding experts.

Clarify Your Terminology

When you talk about these cases in your office, how does everyone refer to them? Are you trying to "pre-authorize" the procedure or "precertify" it? An even better question might be: Does it really matter what you call it as long as you know what you're doing?

Some groups use the terms "preauthorization" and "precertification" interchangeably; others don't. Groups that distinguish between the terms usually say that obtaining precertification means the carrier says, "Yes, you can perform that procedure for that diagnosis." Pre-authorization means the carrier says, "Yes, you will be paid for performing the procedure."

If you look at the terms in this light, preauthorization is like a guarantee for payment, whereas precertification might not be (instead, precertification validates the medical necessity of a test, procedure, surgery or inpatient hospital stay). When talking with a carrier, try to avoid confusion by being sure everyone uses the terms in the same manner.

Realize that it can still be difficult to get paid for some procedures, even with preauthorization. However, many coders say that obtaining precertification or pre-authorization is important and generally gives you some leeway for payment.

Check Carrier Guidelines

Most injection procedures and more detailed procedures such as spinal cord stimulator or pain pump placement must be preauthorized, says Tammy Reed, CPC, anesthesia department billing manager for Oklahoma University Health Science Center in Oklahoma City. Codes to watch for include:

 

  • Neurostimulator codes 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling) and 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver)

     
  • Pain pump codes 62360 (Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir), 62361 (...non-programmable pump) and 62362 (... programmable pump, including preparation of pump, with or without programming)

     
  • Lumbar epidural steroid injection code 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).

    "Some carriers don't require precertification but do have medical-necessity issues to establish," Reed says. "We always contact the carrier to see if precertification is required or if there is a medical-necessity issue we should investigate first."

    Another good question to ask is whether the carrier covers the procedure when it is conducted in an ambulatory surgery center (ASC). This has become a big issue for injection procedures, so verify the carrier's guidelines before proceeding.

    Get Information Up Front

     When it's time to complete a claim that you've pre-authorized, the legwork you did before scheduling the procedure can make a big difference in your bottom line. Reed recommends these tips to keep the process moving:

     

  • Make the preauthorization call count. Get as much information as possible from the carrier when you call to preauthorize a procedure. Check the patient's eligibility and benefits information (including how much the carrier will cover, what the patient's deductible is, and whether the facility is in network).

    Also ask if there are any medical-necessity issues that should be addressed, such as certain diagnoses the carrier requires before paying for a procedure. Caution: Remember that it is not enough to link the procedure code to a correct, payable ICD-9 code, says Scott Groudine, MD, an Albany, N.Y., anesthesiologist. The accompanying diagnosis or clinical signs and symptoms must be present for the carrier to pay for the procedure.

     
  • Preauthorize as many services as possible. If the physician plans to administer a series of injections over a period of weeks, try to authorize the entire series instead of separately preauthorizing each injection. Reed says that most carriers will allow you to do this, especially for procedures such as epidural steroid injections that the physician typically performs in a series.

    Report standard ESIs with 62310 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or 62311 (... lumbar, sacral [caudal]).

    You might also report 64479 (Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level) or +64480 (... cervical or thoracic, each additional level [list separately in addition to code for primary procedure]) if the physician uses the transforaminal approach to the epidural space (though Groudine says physicians use this approach less often). 
     
    One drawback to preauthorizing everything at once occurs if the physician decides to perform a different type of injection during the series. "If we don't call to change the precertification, we can have problems getting the claim paid," Reed says. "These claims usually have to go through the appeals process."

    Obtaining information about the patient's plan up front  can sometimes help avoid problems in the long run. "It takes time for our staff to get the precerts, and this can delay patient care," Reed says. "But it can also help identify potential problems up front such as patients with a pre-existing clause or patients who have carriers with a limited network of approved facilities."

    Timing Can Be Everything

    Many preauthorizations and precertifications go through without too many problems, especially if you've documented medical necessity and you follow the carrier's process.  But the amount of time it takes to receive preauthorization can become a problem in itself, Reed says.

    "Our biggest problem is trying to get a precert in a timely fashion who are in extreme pain," she says.  "It sometimes takes several days to get a precertification, and for patients in pain that's too long."

    Tip: How you expedite the approval depends partly on what's causing the delay.  "If it's a timing issue, the patient and his primary-care physician are our best resources for expediting the process," Reed says.  "If it's a medical-necessity issue,  our physicians aren't opposed to speaking with the carrier's medical director about pre-authorizing the procedure."

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