2011 Coding Changes for Transforaminals Affect Reimbursement

November 8th, 2010
 
With the 2011 coding changes to transforaminal injections practices should contact their managed care companies and negotiate higher rates since this will include the fluoroscopy component.
The CPT 2011 coding change for pain management bundles fluoroscopy into all of the transforaminal injection codes.  For many practices the transforaminal codes are a high volume procedure and careful analysis should be done to protect revenue.  With the inclusion of the fluoroscopy component in the procedure code, pain practices stand to lose any money attributed to the 77003 component billed with the 64479-64484 codes.  While evaluating the Medicare RVU's  you must look at both the 2010 RVUs for fluoroscopy and the first level transforaminal and then compare it to the 2011 RVU for the first level of transforaminal.  This will equate to at least a loss of between a half and one RVU for each procedure performed based on your site of service and ownership of the equipment.  For those fee schedules tied to Medicare this is horrible news.  If your managed care contracting is done at as a flat fee service you should address this disparity before the beginning of 2011.  For many groups this loss of income represents between $30.00 and $150 on each episode of care.  These are challenging times for pain management physicians and aggressive contracting is essential to being able to keep revenue at respectable levels.

2011 OIG Work Plan Lays Out Compliance Work

October 5th, 2010

The 2011 OIG work plan was published this month and gives us guidance as to the government’s concerns regarding physician claims.  ACE recommends focused audits in the areas of the physician work plan that would apply to your practice.
Once again Evaluation and Management coding top the list of government concerns.  There are three focuses regarding evaluation and management services.  First, all services are to be coded appropriately.  They stress that the E & M codes must accurately reflect the type (new or established), status of the patient, setting and complexity of services provided.
Second, they will review for appropriate payment of services.  They specifically note an increased frequency of medical records with identical documentation and state that services must reflect what is done during the visit.  Finally, they will be looking at all E & M services that are made during the surgeon’s global surgery period.  This is an opportunity to evaluate your acute pain services and be sure documentation is adequate in supporting the medical necessity of an anesthesia provider and that medical decision making supports the evaluation and management code billed.
Physical therapy services continue to be on the government’s list.  Therefore, ancillary services provided in the pain clinic will need to be put on the compliance committee’s agenda.    Specifically the OIG is looking for services that are not medically necessary.  Medicare’s definition specifically states that physical therapy services that do not meet the criteria to improve the functioning of a malformed body member are not medically necessary.  Physician documentation should include a plan of what function we are working to improve and an ongoing assessment as to the improvement of that function based on the course of physical therapy.  They will also be using statistical sampling to identify counties with high utilization and compare those counties with national averages, noting that high utilization may indicate fraud.
Diagnostic tests and the medical necessity of requesting the test will be reviewed as part of the 2011 work plan.  For pain clinics routinely ordering MRIs, EMGs or EEGs the documentation in the patient’s medical record should support the medical necessity for ordering the test.  The work plan specifically identified duplication of tests as a focus so it will be imperative for pain physicians to coordinate with primary care and other specialists on what testing has been previously done before ordering a diagnostic study.
Laboratory services are also on the work plan and with the number of pain clinics now billing for urine drug screening this would also need to be a focused audit for the compliance committee.  They are specifically looking for increased utilization stating that services paid in 2008 which was approximately $7 billion, represents a 92% increase from 1998.  They are particularly going to examine how each physician specialty, diagnosis and geographic difference in the practice of medicine affect laboratory test ordering.  Pain management groups should be sure that rationale for ordering or performing urine drug screens is specifically addressed in the medical record.
Finally, the OIG will continue to focus on the compliance of Provider’s regarding the rules that govern the assignment of benefits.  Pulling assignment agreements to be sure the anesthesia group is adequately covered under the hospital assignment as well as checking all facilities where providers work is necessary to be sure that the written agreements comply with the Medicare regulations.  Groups should also assess that balanced billing to patients is appropriate and being done within Medicare requirements.
The OIG work plan lays out the governments areas of focus for the upcoming year.  It is necessary for compliance officers and auditors to include these focus areas along with high risk areas for the practice in their audit plans.  I hope you find this information helpful and if we can be of assistance to you, please feel free to call.
 
This alert was contributed by Devona  Slater, ACE President & Compliance Auditor

Highmark Post Payment Audit Reveals 73% Error Rate

September 21st, 2010

A recent audit performed by Highmark Medicare Services discovered that incorrect billing of procedure codes 99204 and 99205 occurred in 73% of records reviewed.  The issues include the following:  1) Incorrectly coding the level of service, 2) Lack of an accepted form of provider signature, 3) Incident to guidelines not supported by documentation, 4) Documentation does not support services billed.
 
Result:  An edit on procedure codes 99204 and 99205 will be put into action for providers in all specialties requiring written documentation to support the level billed.
 
You can find the full bulletin here:  www.highmarkmedicareservices.com/bulletins/partb/news09202010.html