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.