Pain Management Coding Alert

Make sure both providers sign off on these claims.

At times, your pain management specialist might perform postoperative pain management for a surgeon's patient. When this occurs, you need to be sure to team up with the surgeon to make sure you both get your claims paid properly.

Keep these tips in mind the next time your pain management specialist performs postop pain management for a surgeon.

Make Sure Surgeon Doesn't Provide Pain Management

In most cases, the operating surgeon handles the patient's postoperative pain management for two reasons: It's not usually very complicated and it's included in the surgical fee. The surgeon might request help from a pain management provider, however, for cases that are more complicated or that require more focused postop care.

"We do see a lot of postop pain management," says Cindy Hinton, CPC, CCP, CPCO, of Advanced Coding Solutions, LLC, in Franklin, Tenn. She cites three types of pain management care that they see most often:

• Femoral nerve blocks - 64447 (Injection, anesthetic agent; femoral nerve, single) and 64448 (... femoral nerve, continuous infusion by catheter [including catheter placement])
• Interscalene blocks - 64415 (Injection, anesthetic agent; brachial plexus, single)
• Lumbar epidurals - 62319 (Injection[s], including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral [caudal]).

"Many of these are provided following joint replacement surgeries as well as other extensive orthopedic procedures," Hinton says.

Get Both Providers to Document Service

According to the Correct Coding Initiative's (CCI's) guidance, a pain specialist cannot code for routine postop pain management care "unless separate, medically necessary services are required that cannot be rendered by the surgeon."

Because of this stance, you'll need documentation from both sides of the care before your provider can charge for the service.

From the surgeon: The surgeon should request in writing that the pain management specialist provide postop pain management care for the patient.

From the PM specialist: Your provider's notes should include details regarding the service she performed, the substance she injected, the site of the injection, and the substance dosage.

Traditionally, providers have documented the surgeon's request for postop pain management, either on the record or a separate block form. This isn't always the best tactic, however.

"The problem with this is that auditors are not seeing corresponding documentation from the surgeon, such as orders for the pain block or catheter," says Kelly D. Dennis, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. "As there have been some cases of insurance companies recouping payment when the documentation did not support the surgeon's request, it would be a good idea to make sure the surgeon is also documenting the need for postoperative pain management by the ... provider."

The procedure note should be legible and should include the following:

• Clear documentation that the surgical procedure is not dependent upon regional anesthetic technique
• Clear documentation of the time spent on placement of the block or catheter
• Clear documentation of the procedure.

Plus: If your provider uses ultrasound guidance for the block or catheter, Dennis says you should also have procedure notes that are in line with the code description in CPT^®:

• Evaluation of the potential access site
• Documentation of selected vessel patency
• Concurrent real-time ultrasound visualization of vascular needle entry
• Permanent recording and reporting.

Document Diagnosis Clearly With M Codes

You'll also need clear documentation of the patient's diagnosis supporting your provider's service.

Example: The surgeon requests postop pain management care for a patient following shoulder surgery. If the surgeon doesn't document a specific diagnosis, you should code based on the patient's signs and/or symptoms.

In the case of shoulder surgery, you could possibly report one of three choices, depending on the circumstances:

• M25.511 - Pain in right shoulder
• M25.512 - Pain in left shoulder
• M25.519 - Pain in unspecified shoulder.

Final point: As this is not "routine postoperative pain" handled by the surgeon, you might also need to report a code from the G89 section. Dennis says these options could include:

• G89.11 - Acute pain due to trauma
• G89.12 - Acute post-thoracotomy pain 
• G89.18 - Other acute postprocedural pain.