Pain Management Coding Alert

Documentation always helps postop pain reimbursement chances.

If a surgeon places your provider in charge of a patient’s postoperative pain management, documentation should be your first, and last, concern before filing the claim. It’s just that important to securing reimbursement for your provider’s services.

Help’s here: We checked in with from Cindy Hinton, CPC, CCP, CPCO, of Advanced Coding Solutions, LLC, in Franklin, Tenn., on submitting a separate claim for the post-op injection or catheter placement.

Here’s what she had to say on the issue.

Rule 1: Different Physician Must Perform Surgery

First, you must ensure that the injection or catheter placement was administered by a different physician (i.e., your provider) than the surgeon who performed the surgery. Medicare requires the surgeon to document in the patient’s medical record why referring the postop management to your provider is necessary.

“Typically, there’s documentation to indicate the surgeon requested … pain management in an attestation on the record,” says Kelly Dennis, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Rule 2: Complete Separate Postop Report

Second, your provider should complete a separate procedure report for the postop pain management procedure. It should not be part of the surgeon’s operative report. Keeping separate reports isn’t absolutely necessary, but might help the payer better understand the situation — which can speed up reimbursement.

Rule 3: Work Out Injection Situation

In most cases, Medicare considers injections routinely used for postoperative pain control to be bundled into the surgeon’s global services. If you aren’t able to file separately from the surgeon, you’ll need to make an agreement with the surgeon regarding how to get your provider’s payment from the surgeon’s reimbursement.