Wiki Interventional Pain Management Office Questions

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mamoore56

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Hello all,
I am working with a Pain Management doctor and have questions posed to me by the provider. I have worked in internal medicine, family medicine and ENT but rather new to pain management so I would really appreciate any feedback from forum.....
1. Is is necessary to document all vitals in the visit note if a patient is just being seen for a pain management question or RX refill for pain management diagnosis? I understand if an injection is involved or a procedure, then yes, you would need all vitals documented in the visit note. The nurse stated there are 3 requirements for a visit note when an injection is involved and if so, I would like to know these 3 requirements?
2. The doctor asked for a definition of medically appropriate as this is mentioned in E/M coding guidelines. Could someone provide an example of a medically appropriate note or refer me to a source with an example?
3. I would like to provide the doctor with an example of a level 3 E/M code and level 4 E/M code with the new 2023 guidelines but have not been able to locate good examples. Does anyone have examples I can show the doctor? If not, please refer me to a good resource for the data?
Thank you and I appreciate any information you can provide.
 
I understand how sometimes these questions can be daunting. Many times they want a black and white answer and a "just do this every time" but that's not how it works unfortunately.

1. From a coding standpoint it is not necessary to document all vitals just to tick off boxes for an E/M. However, is it medically appropriate as part of the history? Maybe. It depends. The nurse is probably speaking from a clinical practice/consent/med-legal standpoint. Injections are procedures/live in the surgical section of the CPT book (e.g. 20610, 64490) and require procedure documentation. She should be able to tell you the 3 requirements, right? We discussed procedure note (injection) documentation requirements here recently: https://www.aapc.com/discuss/threads/procedure-note-documentation.192019/?view=date#post-526140

2. & 3. I would take some of the providers own notes and audit them against the guidelines to show them their own work/coding. See below for snip from the AMA definitions - it is not for us (coders) to tell them what is medically appropriate, that's clinical and up to the provider. Sometimes using external examples is a slippery slope. Many times EHR vendors will try to give providers templates/macros which is a risk to the practice. While there can be a place for it, it is a dangerous area.

Definitions and other info is found in the AMA guidelines:
"E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of these E/M service codes."

FL MAC Part B resources on E/M would help you. Use the interactive E/M worksheets and FAQs sections: https://medicare.fcso.com/Landing/233030.asp
https://medicare.fcso.com/EM/0476893.asp https://medicare.fcso.com/EM/175804.asp

Good info on"medically appropriate" https://insideangle.3m.com/his/blog...vices-medically-appropriate-history-and-exam/

Resources here may help: https://www.aapmr.org/quality-practice/coding-resources/e-m-coding https://www.aapmr.org/quality-practice/coding-resources
https://karenzupko.com/interventional-pain/ https://www.aaos.org/quality/coding-and-reimbursement/coding-community/ https://karenzupko.com/resources/interventional-pain/

Helpful links here: https://www.cms.org/articles/2021-cpt-evaluation-and-management-e-m-coding-changes
 
amyjph said:
I understand how sometimes these questions can be daunting. Many times they want a black and white answer and a "just do this every time" but that's not how it works unfortunately.

1. From a coding standpoint it is not necessary to document all vitals just to tick off boxes for an E/M. However, is it medically appropriate as part of the history? Maybe. It depends. The nurse is probably speaking from a clinical practice/consent/med-legal standpoint. Injections are procedures/live in the surgical section of the CPT book (e.g. 20610, 64490) and require procedure documentation. She should be able to tell you the 3 requirements, right? We discussed procedure note (injection) documentation requirements here recently: https://www.aapc.com/discuss/threads/procedure-note-documentation.192019/?view=date#post-526140

2. & 3. I would take some of the providers own notes and audit them against the guidelines to show them their own work/coding. See below for snip from the AMA definitions - it is not for us (coders) to tell them what is medically appropriate, that's clinical and up to the provider. Sometimes using external examples is a slippery slope. Many times EHR vendors will try to give providers templates/macros which is a risk to the practice. While there can be a place for it, it is a dangerous area.

Definitions and other info is found in the AMA guidelines:
"E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of these E/M service codes."

FL MAC Part B resources on E/M would help you. Use the interactive E/M worksheets and FAQs sections: https://medicare.fcso.com/Landing/233030.asp
https://medicare.fcso.com/EM/0476893.asp https://medicare.fcso.com/EM/175804.asp

Good info on"medically appropriate" https://insideangle.3m.com/his/blog...vices-medically-appropriate-history-and-exam/

Resources here may help: https://www.aapmr.org/quality-practice/coding-resources/e-m-coding https://www.aapmr.org/quality-practice/coding-resources
https://karenzupko.com/interventional-pain/ https://www.aaos.org/quality/coding-and-reimbursement/coding-community/ https://karenzupko.com/resources/interventional-pain/

Helpful links here: https://www.cms.org/articles/2021-cpt-evaluation-and-management-e-m-coding-changes
Click to expand...
Thank you Amy, this was very helpful. Have a great day!
 
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