Welcome to the new Outpatient Surgery website! Check out our login FAQs.
Should You Add Pain Management?
Patients' needs, low overhead and high volume present the ideal opportunity.
John Dombrowski
Publish Date: October 10, 2007   |  Tags:   Pain Management

Is there a demand for pain management services? The answer, without hesitation, is a resounding yes. It's also a very lucrative specialty to add to your facility's offerings, given current demographics, patients' post-surgical needs, the procedures' low costs and the potential for a high case volume. These factors have created such a favorable environment for pain management care that I'd be surprised if there are many facilities that haven't considered adding the service. Here's how it could work for you.

Outpatient opportunities
Pain medicine is nothing new, but it's continuing to gain in popularity, especially among patients. We're seeing "the graying of America" as the baby boom generation is approaching retirement. They're facing their own musculoskeletal issues - osteoarthritis, lumbar canal stenosis and degenerative disc disease among them - and most of them don't want to live with pain as their grandparents did. They want to be active, mobile and pain-free, and they want it yesterday. Pain management fits the bill.

Earlier in the decade, internal medicine specialists had been able to provide pharmaceutical pain relief with such COX-2 inhibitors as Vioxx and Bextra, but after manufacturers removed those drugs from the market for fear of cardiovascular risks, that took one option off the table. Another pharmaceutical option, the administration of weak or potent opioids, exists under the intense scrutiny of the U.S. Drug Enforcement Agency and the worrisome uncertainty that patients will fail to comply with their correct usage.

The drawbacks of these drug options open the door for an increase in performing procedural pain management in an outpatient setting, be it in a hospital outpatient department or freestanding surgery center. Regardless of the setting, keep in mind that patients in pain and seeking relief don't want to spend a lot of time waiting, but would rather undergo a faster, easier, in-and-out process.

Meeting the need
As a service line, pain management is a natural extension to specialties that frequently deal in chronic pain: the cervical and lower back pain of orthopedics and neurosurgery, the foot and leg pain of podiatry, even the pelvic and prosthetic pain of urology and gynecology. Surgeons practicing these specialties at your facility have an automatic audience for pain management referrals.

If the patient population isn't as readily apparent, however, and you want to determine the need for pain management services in your community, poll the providers who bring cases to your ORs. Ask them if there's a need in the office for pain services. Ask them if and where they're referring their patients for relief. Then you'll have your answer - and your opening.

Proposed Medicare-approved ASC List

HCPCS

Short Descriptor

2007 ASC Payment Group

2007 ASC Payment Rate

2007 OPPS Payment Rate

2008 Payment During 50/50 Transition

2008 Payment After 50/50 Transition

22521

Percutaneous vertebroplasty, lu

9

$1,339.00

$1,542.47

$994.58

$994.58

22522

Percutaneous vertebroplasty, ad

1

333.00

1,542.47

994.58

994.58

62311

Inject spine l/s (cd)

1

333.00

392.62

293.08

253.16

64475

Inj paravertebral l/s

1

333.00

392.62

293.08

253.16

64476

Inj paravertebral l/s add-on

1

333.00

341.23

276.51

220.03

64483

Inj foramen epidural l/s

1

333.00

392.62

293.08

253.16

64484

Inj foramen epidural add-on

1

333.00

392.62

293.08

253.16

64622

Destr paravertebrl nerve l/s

1

333.00

765.89

413.42

493.85

64623

Destr paravertebral n add-on

1

333.00

392.62

293.08

253.16

G0260

Inj for sacroiliac jt anesth

1

333.00

341.23

276.51

220.03

Since pain management is the crown jewel for a lot of surgical facilities, given its fiscal benefits, many facilities line up a pain doc on staff when they open. If you didn't, though, it won't be that hard to add one. As mentioned, your surgeons may already have contact with pain management doctors. Your call asking them whether they'd be interested in bringing pain procedures to your surgery center, and very likely reaping the synergy of new cases referred by the surgeons there, could serve to convince them.

Otherwise, look to your local or regional hospitals. Are there anesthesiologists looking to leave their hospital-based situations for more career freedom and control? As an anesthesiologist myself, I'm biased as to their capabilities, of course, but physiomedical rehab physicians can also serve well as pain management providers.

As always, when you're adding new surgeons to your staff, be sure to do your due diligence and thorough credentialing. You don't want to leave your facility open to liabilities that could have been avoided.

Costs and returns
The considerations involved in adding a new service generally revolve around two main points: What will it cost the facility, and what will the facility get in return?

Good news for freestanding surgery centers: The cost can be quite low, as the amount of equipment required is minimal. Capital equipment is limited to a C-arm or other intraoperative imaging system and a fluoroscopy table. Most facilities offering related specialties already have this equipment. (If not, the two can be purchased for $50,000 to $70,000.)

Besides those pieces, costs are less than $50 per patient. A tray of supplies, including syringes, needles, iodine prep and sterile drapes, costs about $20 per case. Medications, which include multi-dose vials of local anesthesia and the steroids of your choosing, average about $10 per patient.

Pain management's staffing needs are minimal. In terms of OR personnel, you'll need someone to run the C-arm and a nurse to assist the surgeon, or whatever your particular state's regulations require.

Basic pain management cases are short - the patient's pain is diagnosed and located, an injection is administered - and take about 15 minutes apiece. This is one of the specialty's major rewards. If you group cases together into a single block for efficiency, you can do a large number of cases in a short amount of time.

Let's say you charge a minimum of $500 per patient procedure. In terms of a cost-benefit ratio, $500 every 15 minutes can't be beat. That's $2,000 an hour. I don't think any other specialty comes close to that.

Plus, in most cases, you've locked in the repeat business. One patient who comes in with a back injury can be expected to return for three to six procedures over 12 months. With each patient making multiple visits, you've increased your market share and you can quickly recover your costs.

Advanced methods
If you've got qualified pain management physicians on staff, there are advanced treatments beyond basic pain services that you can perform in the outpatient arena.

In radiofrequency ablation therapy, instead of injecting medication, you're inserting a probe to direct radio waves at a targeted location, heating up and destroying the nerves at a pain-generating site. This temporary treatment will ward off the patient's pain until the nerves grow back in six to 12 months.

The next level in the continuum of care is the implantation of spinal cord stimulators. While still a minimally invasive process, this procedure takes pain management out of the procedure room and into the OR and from local to general anesthesia. The stimulator, a sort of pacemaker for pain, involves wire leads and electrodes placed into the anatomy of the lower back to generate electrical impulses that prevent pain signals from reaching the brain.

Both of these advanced pain procedures add costs. In the case of radiofrequency ablation, the necessary instrumentation costs about $20,000 to $30,000, while the cost of the spinal stimulator hardware is passed on to the patient. But in both cases, they stand to differentiate your facility from others as offering unique services. It's good public relations: You can profit from these procedures, but you'll also distinguish yourself in the community as a cutting-edge pain management provider.

Declining Pain Reimbursements? Here Are Four Ways to Cope

Some 40 million Americans suffer from chronic pain, 78 percent of which is neck- and back-related, according to the National Institutes of Health. In 2003, healthcare providers spent $7.73 billion in treating chronic pain, a figure that's been estimated to reach $10.29 billion in 2007.

Pain management is a field that's large and growing, and OR managers have recognized that its procedures are a high-volume, low-cost source of revenue. Lately, though, they've also been asking whether the specialty is going to be hit hard by the Centers for Medicare and Medicaid Services' 2008 and 2009 changes in reimbursement.

To the extent that we can determine from CMS's proposed rule, the answer is yes, just like every other specialty's going to see significant impacts in payment. The chart on page 64 shows how the top 10 most commonly performed pain management procedures will be affected by proposed payment system and reimbursement rate changes between 2007 and 2009.

How can surgery centers that have taken on pain management services combat declining reimbursements? Here are four tips.

1 Capture every level. In pain management procedures, you're paid for every individual vertebral level that the provider works on. In a three-level facet joint injection, for instance, you can code 64475 for the first level injected - presently reimbursed at $333 - and 64476 for the two subsequent injections at $166.50 each, 50 percent of the initia reimbursement. That's $666 in a 15-minute case, if you remember to add on the additional codes. You get paid for each level, so it's essential to capture every level that's done.

2 Fifteen-minute cases. Lumbar epidurals, lumbar facets and other common pain management procedures are and should be short cases. Basic pain management procedures that last longer than 15 minutes are costing you in volume and in profits. Strive for fast turnovers and turn your cases every 15 minutes.

3 Bill bilaterally. Some pain management codes are unilateral. Epidurals, for instance, are only injected in one location. But others, such as facet joint injections, can be billed for left- and right-side procedures. If the physician injects both sides on a bilateral procedure, Medicare and other payers reimburse 150 percent of the base - if you code for both. Many people forget the bilateral.

4 Fluoroscopic guideline. Medicare and Medicaid bundle fluoroscopic guidance into the coding for select pain management procedures, but most private payers don't. If you want to reap the reimbursement for fluoroscopic guidance from these non-governmental insurers, remember to bill with the appropriate fluoroscopic guidance code. The most common of these codes used in pain are 77002 and 77003. - Linda Van Horn, MBA

Ms. Van Horn ("[email protected]")) is president and CEO of 21st Century Edge, a Kansas City, Mo.-based healthcare consulting firm specializing in interventional pain management.

DID YOU SEE THIS?