Pain Management Medical Billing Guidelines

pain management medical billing guidelines

Pain is a common symptom of a variety of disorders, conditions, diseases, and injuries. Everyone experiences it at some point in their lives, whether for a short period of time (acute pain) or for years (chronic pain). As a result, pain management billing services are an essential component of RCM. 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.

Pain relief from injury, disease, chronic condition, addiction, or any combination of these is a noble and rewarding task and requires skill, determination, and an eye for patients’ reactions and body language. Those qualities and instincts are enhanced when you have intelligent, specialty-specific, hands-free automation on your side for:

  • Ensure maximum claim value with a nearly 100% success rate on first-time HCFA, UB, Workers Compensation, and No-Fault clearinghouse claims.
  • making it possible to capture both patient responsibility balances and out-of-network payments in advance
  • keeping patients, staff, and providers engaged while staying mobile
  • Click-free/hands-free EHR and charting with PDMP/NCPDP-enabled e-Rx, or the option to keep your current EHR interfaced to the RCM company, or no EHR with the RCM company’s e-superbill
  • Adherence to CMS initiatives, such as AUC/clinical decision support and the 21st Century Cures Act

Pain Management Medical Billing Guidelines

With millions of people in the United States suffering from severe and ongoing pain, chronic pain management has emerged as a serious public health issue, costing the government billions of dollars in lost time and productivity while having a significant impact on people’s lives. According to a CDC survey, approximately 50 million Americans, or 20.4% or 1 in 5 adults, suffer from chronic pain. Successful billing and coding are only half the battle when it comes to increasing practice income. New state and federal regulations have complicated pain management billing.

Recently, pain management has faced billing challenges such as extending prior authorization requirements, lowering fee schedules, and shifting financial obligations to the patient. There are guidelines to improve your pain management billing collection after recognizing and comprehending these issues.

Avoid Billing Procedures Based On Summaries

One of the most common billing and coding mistakes in pain management is charging a process based entirely on a summary. According to Medicare, you can only bill for operations that are detailed in the report’s text. It implies that for coding purposes, programmers must go beyond a brief review of the document.

Pain Management Documentation (PMD)

Medical documentation proves that all procedures are medically necessary. Similarly, pain management documentation (PMD) is critical for effective pain management treatment. It is a method for healthcare professionals to communicate about patients’ problems, therapies, and reactions. With precise and detailed pain management documentation, claim denials can be avoided. Once given to the business department, coders must be professional in clarifying information discovered in notes and coding correctly based on the most recent coding recommendations.

Correct Errors In Medical Records

Complete documentation is required to ensure that payers pay for treatments and that medical record inaccuracies are addressed adequately. Within patient records, physicians should never erase words or use correction fluid. If a mistake is discovered in a patient’s medical history, a single sentence should be written across it in ink, with the word “error” above it, and the repair should be completed. Any corrections to the record must also be approved by a physician.

Fluoroscopy Billing

The majority of pain management practices make the mistake of charging fluoroscopy separately. Many pain management codes, such as discography, articular joint, spinal steroid injections, and radiofrequency ablations, necessitate fluoroscopy.

Check to see if the treatment is paid for as a package, such as SI joint (27096), medial branch blocks, and facet injections, or if it is paid separately, such as fluoro guidance codes for peripheral joints. If you charge for fluoroscopy separately, your claims will be rejected because they are duplicates.


Modifiers help in the clarification of the process, and using incorrect modifiers may result in claim denials. The following modifiers are commonly used on pain management billing:

-LT stands for anatomically left; -RT stands for anatomically right.

50: Bilateral procedure

59: indicates that a service or operation is unique and distinct from other services provided on the same day

52: incomplete procedure; delaying part of the procedure for considerations other than patient well-being.

53: incomplete procedure; the physician decides to terminate the procedure for the patient’s safety.

Modifier -50 must be used when coding bilateral operations and denotes a procedure done on both sides of the patient’s body in a single session. Forgetting modifier -50 or coding each body side is a typical error.

Up To Date Payer Policies And Guidelines

Given a large number of insurance companies, providers, and coders. To maximize compensation, it is critical to stay up to date on insurance payer policy changes, which necessitates investigative efforts to collect information from changes and documentation received from numerous payers. The most significant changes in coding and billing are generally disclosed in the fourth quarter of the previous year, with January 1st effective dates. However, information may change throughout the year. Telemedicine adjustments, for example, influenced patient E/M codes and ICD-10-CM codes during the COVID-19 pandemic.

Following payer regulations and billing guidelines will result in fewer denials and quicker insurance payouts. In the event of a problem, contacting the insurance company may provide additional information and assist you in avoiding late payments. On their websites and provider portals, insurance companies provide up-to-date billing standards and policies. By training your billing and coding staff, you can stay up to date on payer rules and norms.

Mobility, Engagement, and Patient Experience

Pain management is a specialty that can sometimes provide remote healthcare but often requires patients to be seen in-office by the physician. Your system or RCM provider should have features and options that support both types of visits, including platforms that make in-office visits as risk-free as possible by minimizing contact with:

  • Telemedicine

Telemedicine for Pain Management, ideally via an iOS/Android app from the system’s vendor or RCM company (rather than a second or third party), is the pinnacle of remote healthcare technology. The patient and provider could easily initiate sessions at the appointment time. When sessions are completed, they are presumably timestamped by the system and coded correctly for correct and timely reimbursement.

However, apart from the COVID-19 factor, telemedicine is ideal for patients who have difficulty coming into the office or who must travel a long distance to get there. Other than the provider conducting the session, telemedicine requires almost no office resources. It engages patients in a novel and powerful way.

  • Remote Patient Monitoring

A remote patient monitoring (RPM) option for Pain Management monitors and alerts patients’ vital signs. RPM is a powerful adjunct that elevates telemedicine, but either platform should be deployable as needed.

RPM generates revenue and, of course, improves patient engagement significantly. The RCM company should have an option for this.

  • Patient Portal

It’s an engagement tool that keeps patients connected with you in so many ways. An iOS/Android Patient Portal which makes your practice accessible to patients 24 x 7 x 365 for scheduling appointments, completing questionnaires, which works to make intake much more efficient, paying balances due online, empowering patients to edit demographics/insurance as allowable by you, and even message (“chat”) reducing phone time. The portal should notify patients of new or pending items to be completed, messages to be read, and generate reminders about their healthcare.

  • Interactive Appointment Reminder

As previously stated, interactive appointment reminders and balance due to texting keep appointments solid and revenue flowing. Texts for appointments could also include special instructions and the location of the appointment.

The billing guidelines are customized by every payer even though insurance companies follow Medicare guidelines. There were substantial changes in payer policies and guidelines during the pandemic. Therefore, it is essential to stay updated on recent changes in Payer policies and guidelines to ensure maximum reimbursement.

Considerations When Evaluating Pain Management Billing Services

  • Your claims should be managed by specialized processing professionals familiar with the pain management requirements of worker’s compensation.
  • Payer pre-authorizations should be acquired and kept on file until a new authorization is necessary for each procedure.
  • The majority of delayed or refused claims are due to coding errors — A pain management billing specialist should understand and have experience with the specialized pain management codes.
  • One of the most significant advantages of hiring a reputable medical billing service provider is that they understand and work closely with a range of payers and are familiar with their unique requirements.

Outsourcing pain management medical billing services allows medical practitioners to focus on patients rather than back-office tasks. Outsourcing also has the advantage of lowering claim denials and providing comprehensive and accurate coding. A competent medical billing business should include extra services to handle your revenue cycles, such as A/R management for patients and coverage, modifications, and patient demographics.

Zee Medical Billing has experience in pain management billing solutions. We provide contracting and credentialing services. We guarantee proper code optimization and prevent denials.

For pain management billing-

Call @ +1 (224) 999-6997


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