Pain is one of the most common signs of several disorders, conditions, diseases, or injuries. Everyone goes through it at some point in their lives, from a short time (acute pain) to years, also known as chronic pain. That is why pain management billing services are a vital part of RCM.
Acute pain, is the kind of pain that goes away soon after the condition is treated. Pain management services centres have a significant growth market due to many patients affected by chronic pain. Even though there is a huge growth opportunity for the providers, medical billing for pain management services is challenging. Correct medical billing does half the job for any healthcare practice to be successful.
Revenue cycle management is an integral part of any healthcare provider and physician’s practice. Some of the significant factors that should be considered for pain management services’ billing and revenue enhancement are listed below.
Revenue Enhancement & Billing for Pain Management Services:
The ultimate goal of any healthcare practice is to provide safe patient care and make them “pain-free” as much as they can. Besides providing patient care, getting reimbursed for the medical services performed by healthcare providers is also essential. In order to get reimbursed, the most critical part of medical billing is to bill for the services or procedures performed correctly. It is crucial to code so that your healthcare practice receives the highest reimbursement without over-coding. Pain management services covered by Medicare Part B (medical insurance) include:
- Behavioral health integration services
- Physical therapy
- Occupational therapy
- Manual manipulation of the spine, if medically necessary, to correct a subluxation
- Alcohol misuse screenings & counseling
- Depression screenings
- Acupuncture for chronic low back pain
Medicare Drug Coverage (Part D) helps pay for:
- Medication Therapy Management programs for complex health needs`.
- Opioid pain medication,
- Prescription opioids, like hydrocodone (Vicodin®), oxycodone (OxyContin®), morphine, codeine, and fentanyl, can be used to help relieve severe pain.
- Some Medicare plans have certain coverage rules to help you use opioids safely. Get more information on drug plan coverage rules.
The following are the two factors to be considered:
Submit a clean claim the first time around:
Healthcare practices should aim to have a 95% clean claim rate. It is a rate at which medical claims are processed and reimbursed the first time of being submitted. Submitting a clean claim leads to fewer claim denials and rejections, faster payments, and a higher reimbursement rate.
One of the most important things to be verified before submitting a medical claim is the eligibility criteria and coverage of the patient. Along with this, some services also require pre-authorization/appointment alerts. Several insurance payers require prior authorization for pain management procedures. Claims are only approved based on the reason behind the treatment, i.e., (proof) that the previous conservative treatment option(s) weren’t effective. This is why the medical necessity behind the pain management treatment should be authorized beforehand.
Challenges in Pain Management Billing Services:
Like every other healthcare specialty, pain management billing also faces several challenges. These challenges can directly impact the healthcare practice’s reimbursement rate and revenue cycle. Following are some of the challenges faced by pain management billing:
Healthcare physicians or providers need prior authorizations by insurance payers for certain pain management procedures. Insurance payers approve procedures with medical necessity or proof that previously conservative treatments weren’t effective. Prior authorization on various pain medications is necessary because claim approvals rely on it.
Medical necessity or control on some particular combination of drugs:
As mentioned earlier, certain pain management procedures require medical necessity or proof behind that particular treatment. Submitting a report on the following is crucial;
- Why is that specific treatment necessary for the patient?
- And whether the combination is proven to be suitable for the patient.
Limitations of the pain management services:
The insurance providers do not cover certain pain management procedures, meaning no reimbursements. Moreover, some procedures can only be performed a certain number of times.
One of the major challenges in pain management is errors in documentation. Any variation between the treatment actually performed and the procedure in documentation can lead to errors in medical billing and coding. This increases the risk of a claim being denied or rejected and can lead to a possible audit. Healthcare providers should be up-to-date regarding all the payer’s requirements and updates for documentation.
Specifying the degree, type, and location of the pain:
When it comes to pain, it has a variable nature and several types, for instance, acute pain, throbbing, stabbing, pinching, sharp, etc. The challenge is to translate the nature, degree, and kind of pain into the specific code. Moreover, the precise location of the pain should also be specified in the documentation by the physician. It is so that a specific code can be used in medical coding.
Failure to follow the above-mentioned factors can result in the claim being denied or rejected. Therefore, affect the reimbursements and revenue cycle of the healthcare practice.
Errors in Pain Management Billing:
Revenue cycle management (RCM) is an integral part of any healthcare practice, and proper medical billing is the backbone of the revenue cycle. Correct medical billing means lesser claim denials, faster payments, and a higher reimbursement rate. However, accurate medical billing requires clean claims to be billed – leading to lesser denials or rejections.
Following are some common errors in pain management medical billing to be avoided:
Billing procedures based on summary: Avoid it!
Billing the procedures based on the mere summary of the report is one of the most common errors in pain management billing. Physicians or medical coders are permitted to bill the services provided and documented in the body of the report only.
Canned reports are the templates physicians sometimes use instead of creating a report from scratch. The error with this is that these reports are not always specific to the patient and the pain management procedure performed. These templates may also lack some essential information required for that procedure’s proper documentation. It may also lack information like exact procedures or the location of the procedure.
Billing Fluoroscopy as a pain management procedure separately:
Fluoroscopy is a medical procedure included in the various pain management procedures. These services/procedures include:
- Intra Articular joint or medial branch block facet joint procedures
- transforaminal epidural steroid injections
- Radiofrequency ablations.
Separately billing Fluoroscopy can result in the claim being denied or rejected based on a duplicate claim for a single procedure. It may cause costly claim denials.
Not using the modifier 50 in medical billing:
Modifier -50 should be used for reporting or billing for bilateral procedures. This modifier provides extra information, specifically representing that the procedure was performed on both sides of the body during one session. Not using modifier 50 for reporting any bilateral procedures is a common mistake in medical billing.
Look out for the changes in guidelines:
Coding and billing guidelines are constantly being changed and updated, along with changes in pain management reimbursements. Insurance payer’s requirements for documentation are also being updated, and they require more detailed & specific patient documentation. Along with policy changes, codes for pain management are also being updated annually. This requires the healthcare providers and physicians to be up-to-date regarding all the updates and changes of each payer’s guidelines to avoid any errors. Mistakes in medical billing and coding directly affect the revenue cycle and reimbursement rate of the healthcare practice.
Tips for improving revenues for pain management practice:
Errors and challenges in pain management billing can affect the growth and revenue cycle. Following are some tips and strategies that can help improve the revenue cycle:
Stay updated about the changes in codes and guidelines:
CPT codes are updated annually; not just this, but the payer’s guidelines and requirements can also be updated. This is why healthcare practices need to be up-to-date with every change. These updates include adding new codes and deleting some codes or changes in the payer’s documentation requirements. Using the incorrect code can lead to the claim being denied or rejected, leading to late payments and a lower reimbursement rate.
Documentation must be accurate and complete:
Proper documentation is the key to correct medical billing and revenue cycle management. Healthcare physicians must incorporate detailed procedures in their reports so that correct codes can be used. Also, staying up-to-date with the insurance payer’s documentation requirements for pain management is also essential. Medical claims require complete patient information and medical records. Errors like incorrect patient name, date of birth, gender, eligibility verification, and coverage can lead to a claim being denied.
Reduce errors in medical coding:
Lesser errors in medical coding and billing lead to lesser claim denials, faster payments, and a higher reimbursement rate. However, even minor mix-ups, incorrect digits, or an alphabet can change the code completely, resulting in incorrect medical coding.
Outsourcing medical billing services:
However, outsourcing your hospital billing for pain management services to a medical billing company can result in various benefits. UControl Billing is a well-reputed, results-oriented medical billing outsourced services company. With years of market research, U Control Billing offers:
- Competitive and affordable pricing
- Reduced overall expenses
- Maximized reimbursements
- Billing in 24 hours
- Timely follow-ups
- Streamlined workflows and cash flow
- Specialty and Payer specific coding requirements
- Improved coding accuracy
- Eligibility verification.
- HIPAA Compliant
There are various benefits of outsourcing your pain management billing services. Some of the major benefits of outsourcing billing services include the following:
- Reduced errors in medical claims
- A team of highly experienced medical billing professionals
- More focus on providing safe and quality patient care
- A higher clean claim rate and lesser claim denials
- Faster payments and a higher reimbursement rate
- Improved revenue cycle
When physicians or healthcare practices hear about outsourcing, they usually worry about shifting from their current EHR/EMR. UControl Billing believes in saving your time, efforts, and money. This is why you won’t have to change your EHR/EMR; our team can efficiently perform the necessary tasks on your existing EHR/EMR.
Frequently Asked Questions (FAQs)
1. What are pain management billing services in medical billing?
Pain management services centers have a significant growth market due to many patients affected by chronic pain. When it comes to medical billing for pain management, it gets pretty challenging due to several errors associated. Correct medical billing does half the job for any healthcare practice to be successful.
What are common pain management billing services errors?
Several challenges and errors are associated with pain management medical billing services. Some of the most common mistakes include;
- Incomplete documentation
- Not specifying the medical necessity behind the pain medication or treatment option.
- Prior authorization on several pain management procedures.
- Canned reports
3. What do pain management billing services mean?
Pain management includes treating all types of pain, including musculoskeletal, neuropathic, or spinal. It is a growing field of medicine with the ultimate goal of providing safe patient care and making them “pain-free.” Pain management billing services get pretty challenging, which is why outsourcing them can help you to focus on the ultimate goal.
A couple of years ago, I executed the effective plan of creating a Medical billing and Coding company named U Control Billing. The company aims to bring revolutionary advancements to foster medical billing and coding revenues. As an official member of HIA-LI and MGMA, I feel honored in providing networking opportunities, problem-solving, and improving the revenue management cycle.