Anesthesia Coding Alert

Question: I've read things that seem to indicate that I can bill an E/M visit with the first of a series of pain management procedures when the physician makes decisions and maps out the original management plan. Is this appropriate? The physicians certainly spend more time with the patient during the first of a series of blocks.

Kentucky Subscriber

Answer: During the first visit, the pain management physician "gets to know" the patient by taking her history, discussing treatment options and reviewing test films or reports (otherwise, the anesthesiologist doesn't know anything about the patient's comorbidities and whether they might affect treatment results). Because of this, billing an E/M code is entirely warranted as long as the physician's documentation supports it.

Some clinics recommend that new patients come for an E/M visit prior to treatment at a later date. This helps ensure the physician will be reimbursed for the visit. Some coders also recommend billing for follow-up visits, if the patient has experienced a significant change for the worse, or if some other major event occurred that changed the patient's symptoms, presenting problems, etc. (i.e, the patient has complications or injures another body part after the first treatment).
Your biggest challenge in many of these cases is having proper documentation to support coding the E/M visit (new patient, established patient, or consultation). Many physicians perform the exam but don't document it well. Work with your physicians to be sure they understand the guidelines for appropriate documentation and reimbursement.