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How We Nearly Quadrupled Our Pain Procedures
Tips for staffing, streamlining and billing to increase productivity and efficiency.
Brent Ashby
Publish Date: October 10, 2007   |  Tags:   Staffing

Efficiency, and subsequent high volumes, are among the keys to making pain management work as part of an outpatient facility's case mix. When we opened Audubon Surgery Center in June 2000, we projected our pain management case volumes to be somewhere between 50 and 100 per month. Eighteen months later, we were doing 300 to 350 monthly - in addition to nearly 600 surgical cases. Here's a look inside how we managed to increase and handle our pain management case volumes.

Making space
To accommodate the growth, we knew we'd need to expand. Our ASC is situated in a building that also houses physician's offices, and there was expansion space available on the floor above the ASC. It took us close to a year from the time we realized we needed more space to the time we were able to open a dedicated pain clinic under the Audubon Surgery Center umbrella.

In that time, we developed space plans, contracted the lease and had the build-out done. We had some of the equipment we needed, so the new space didn't require a huge capital outlay for equipment; but we did have to buy another C-arm, several more trays and a few more tables.

We opened the dedicated Audubon Pain Center, which consists of two procedure rooms, a reception area and a pre-/post-op area, on the second floor of our building in October 2002.

It's made handling our large case volumes a lot easier and let us further streamline the pain service.

Easy to staff
When we have just one pain management room running, one RN is assigned to the room with the pain manager to assist with the procedure, and one RN is assigned to admitting and discharging patients. If two rooms are running, we add another RN to work that room.

Because we have two facilities, we schedule the RNs from the ASC to float to the pain center once a week. If we're exceptionally busy on a two-room day, we can float an RN up there for a few hours to help in admit/discharge; an MA or CNA can also help with discharge. It's convenient to be able to use staff who are already on site and who are employees of the center, and they like it because it's a nice once-a-week break from the hectic ASC pace.

We also have two radiology techs - one works part-time, one full-time - who run the C-arms.

Docs and blocks
We have a total of 10 pain managers - a mix of physiatrists (doctors certified as specialists in rehabilitation medicine by the American Board of Physical Medicine and Rehabilitation) and anesthesiologists. They all have half-day or full-day block time, depending on when they joined us.

For many years, only anesthesiologists were performing pain procedures. But over the past several years, physiatrists have begun doing more pain procedures and injections; tapping into that market was helpful in growing our caseload.

All we had to do was ensure we had a superior credentialing process in place. The physiatrist must all be properly trained in sedation techniques, and be able to provide evidence of that training. For example, they can demonstrate through their CV that they've completed sedation training, or they can give us any certificates they've earned for such courses. They must also be ACLS-trained.

Dedicated receptionist
Of all the keys to making the pain service work, our dedicated receptionist and her great communication with the physicians' offices and their schedulers is one of the top two.

Big challenges associated with pain management are appointment cancellations, patient no-shows and patients who were supposed to go to the physician's office for an evaluation, but show up at the pain center instead. Whatever the reason for scheduling problems, communication is critical to keeping them at a minimum.

Our receptionist has a system worked out with the schedulers -they fax her the list of procedures and patient information several days in advance. She then calls the day before for verification, changes and to make sure everything is in order. It sounds easy enough, but I have to credit her with building good relationships with the schedulers (and our patients) to make this happen. Neither side needs to spend a lot of time on the phone, and that's key to making operations run smoothly.

Practical for patients
Everything about the pain clinic has been streamlined to get patients in and out of our facility as quickly as possible.

Patients are scheduled to arrive 10 minutes to 15 minutes before their appointments. They check in with the receptionist and head back to pre-op, where an IV is started. Most of the pain managers use some form of mild sedation - versed or fentanyl - to do the procedures.

The pain manager can do the procedure in 10 minutes to 15 minutes, and another 10 minutes or 15 minutes after that the patient is ready to go home. This is possible because you don't have to take vital signs as often as you do for surgical patients after the patient comes out of the procedure room. We can have a patient in and out of our facility in 30 minutes to 45 minutes.

That brings me to the second key to our success: a customized and streamlined admission and discharge process.

Unlike our surgical patients, pain patients don't have to fast and they don't need lab work, and many are repeat patients who know the routine. When we were treating the pain patients in the ASC, we used surgical pre-/post-op forms, but we found nurses were leaving a lot of areas blank. Even though these areas were inapplicable, the forms looked incomplete. We now have forms exclusively for pain management - they're more condensed and we've simplified the discharge criteria.

Coding and billing hints
The trick with coding and billing is understanding how your contracts are structured. Really, that's the challenge in this whole business, but it's especially important with pain management. Here are a few hints for ensuring you're reimbursed in full.

  • Know which payers want every code itemized, and which don't. For those who want you to break everything out, be sure to code and use the appropriate fee schedules. Some others will only pay for one or two codes, max, based on a percent of charges - there you'll want to lump everything together.
  • At least for now, Medicare still pays ASCs pretty well for pain codes. As many pain procedures involve bilateral injections and/or multiple levels, each procedure can yield two to three facility fees. Medicare and other payers currently pay 100 percent of the highest payment for multiple procedures in a single session and 50 percent for each additional procedure. Local Coverage Determinations and the Correct Coding Initiative apply to both professional fees and facility fees.
  • Stay aware of the nuances in pain codes; some newer procedures can be done, but you have to be sure your payers cover them so you're not doing cases you won't get paid for. If procedures are outside Medicare groupers, get a schedule with insurers for those procedures to be paid. CMS approves two modifiers you can use to report discontinued procedures: -73 (discontinued outpatient procedure prior to the administration of anesthesia) and -74 (discontinued outpatient procedure after the administration of anesthesia).
  • Regarding fluoroscopy, Medicare facility fees include the use of equipment that is directly related to the provision of the surgical service. The technical component of the use of the C-arm is thus bundled into the Medicare facility fee payment. The physician performing the procedure would indicate the professional component (modifier -26) on his claim for services rendered for both needle localization and supervision and interpretation studies. You wouldn't bill the technical component separately to Medicare on your claim.

A growing area
We've built a good pain management base by providing the best of both the ASC and pain-center worlds to our physicians: They can do their pain cases as if it were a single-specialty center, but reap the benefits of investing in a multi-specialty center. Because of that, we have a great - and growing - pain practice.

Medicare-covered Pain Management Procedures

Here's list of Medicare-covered pain management procedures. Most covered pain management procedures fall into groups one ($333) or two ($446). Non physician-owners who perform pain procedures that aren't on Medicare's payment list for ASC facility reimbursement are entitled to the higher site-of-service differential.

CPT 2005

DESCRIPTION

ASA REL.
VAL.

62311

Epidural lumbar/sacral/caudal

8

62310

Epidural cervical/thoracic.

9

62318

Inject. Incl.cath placement, continuous cervical/thoracic

10

62319

Inject. Incl.cath placement, continuous Lumbar/sacral

9

11900

Scar Infiltration (up to 7)

3

11901

Scar Infiltration (over 7)

3

20550

Injection Tendon

3

20552

Trigger Point 1 or 2 muscle(s)

3

20553

Trigger Points 3 or more muscle(s)

3

20600

Small Joint Injection

3

20605

Medium Joint Injection

3

20610

Large Joint Injection

3

27096

SI Joint Injection (Facility use G0260)

7

G0260

Inj for sacroiliac jt anesth (facility use only)

7

64400

Trigeminal Nerve, any

10

64402

Facial Nerve

7

64405

Greater/lesser Occipital nerve

5

64408

Vagus Nerve

7

64410

Phrenic Nerve

8

64412

Spinal Accessory Nerve

7

64413

Cervical Plexus

8

64415

Brachial Plexus

8

64416

Brachial Plexus Continuous infusion

13

64417

Axillary Nerve Block

8

64418

Suprascapular Nerve

5

64420

Intercostal, single

5

64421

Intercostal, multiple

8

64425

Ilionguinal, Iliohypogastric Nerve

5

64430

Pudental Nerve

5

64479

Transforaminal, epidural cerv/thor. 1st level

10

64480

Transforaminal, epidural cerv/thor. Ea. Add'l

6

64483

Transforaminal epidural lumbar/sacral, 1st level

8

64484

Transforaminal epidural lumbar/sacral ea. add'l

5

64475

Facet, lumbar/sacral single

8

64476

Facet, lumbar/sacral additional

4

64470

Facet, cerv./thoracic single

10

64472

Facet, cervical/thoracic additional

5

64445

Sciatic Nerve

7

64446

Sciatic Nerve, Continuous Infusion

12

64447

Femoral Nerve, single

7

64448

Femoral Nerve, Continuous Infusion

12

64449

Lumbar Plexus

N/A

64450

Other peripheral

5

64505

Sphenopalatine

8

64510

Stellate Ganglion

7

64517

Hypogastric Plexus

N/A

64520

Lumbar sympathetic

8

64530

Celiac Plexus

12

62280

Subarachnoid

15

62281

Epidural, cervical/Thoracic

17

62282

Epidural, lumbar/caudal

16

64600

Trigeminal Nerve, any

10

64612

Botox Injection, facial nerve

3

64613

Botox Injection, Cervical spinal muscle

5

64614

Botox Injection, Extremity/Trunk muscles

N/A

62270

Spinal puncture lumbar

5

64620

Intercostal: destruct

10

64622

Destruct Paravetebral Facet, lumbar single

12

64623

Destruct Paravetebral Facet, lumbar ea. add'l

6

64626

Facet joint or facet joint nerve cerv/thor. 1st level

12

64627

Facet joint or facet joint nerve cerv/thor, ea. add'l

6

64640

Other peripheral

9

CPT 2005

DESCRIPTION

ASA REL.
VAL.

64680

Celiac Plexus: destruction by neuro agent

20

64681

S. Hypogastric Plexis: destruction by neuro agent

N/A

62263

Percutaneous lysis of adhesions

20

62264

Percutaneous lysis of adhesions 1 day

14

0027T

Endoscopic lysis of adhesions

N/A

62287

Percutaneous Laser Discectomy

8

99141

Conscious Sedation by physician performing procedure*(see desc.)

3

64550

Tens application

N/A

62273

Blood Patch

8

62290

Discography, lumbar

5

62291

Discography, cervical

5

72275

Epidurogram (with dictation) w/o use 76005

3

72275-26

Epidurogram (with dictation) professional

N/A

73542

Radiological exam, SI arthrography, global

3

73542-26

Radiological exam, SI arthrography, professional

N/A

76005

Fluoroscopic guidance

2

76005-26

Fluoroscopic guidance professional

N/A

76003

Fluoroscpic guidance

7

76003-26

Fluoroscpic guidance professional

N/A

72285

Radiological interpretation, cervical, global

5

72285-26

Radiological interpretation, cervical, professional only

N/A

72295

Radiological interpretation, lumbar, global

5

72295-26

Radiological interpretation, lumbar, professional only

N/A

62350

Implant Catheter

26

62355

Remove implanted catheter

18

62361

Implant non-programmable pump

19

62362

Implant programmable pump

25

62365

Remove implanted pump

16

62367

Analysis pump w/o reprogram

2

62368

Analysis pump with reprogram

3

95990

Refill implantable pump

4

95991

Refill implantable pump

N/A

63650

Percutaneous implant neurolectrode

29

63660

Revision/remove electrode

26

63685

Implant spinal transmitter

23

63688

Revision/remove spinal transmitter

19

95970

Electronic Analysis w/o reprogramming

2

95971

Electronic Analysis w/reprogramming

3

99201

New patient 1

N/A

99202

New patient-2

N/A

99203

New patient-3

N/A

99204

New patient-4

N/A

99205

New patient-5

N/A

99211

Established pt-1

N/A

99212

Established pt-2

N/A

99213

Established pt-3

N/A

99214

Established pt-4

N/A

99215

Established pt.-5

N/A

99241

Consultation-1

N/A

99242

Consultation-2

N/A

99243

Consultation-3

N/A

99244

Consultation-4

N/A

99245

Consultation-5

N/A

99251

In-pt. Consult-1

N/A

99252

In-pt. Consult-2

N/A

99253

In-pt. Consult-3

N/A

99254

In-pt. Consult-4

N/A

99261

F/U 1

N/A

99262

F/U 2

N/A

99263

F/U 3

N/A

- Amy Mowles

Ms. Mowles ([email protected]) is president of Mowles Medical Practice Management, LLC, in Edgewater, Md.

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