Procedural Documentation and Coding

Published on 06/06/2015 by admin

Filed under Physical Medicine and Rehabilitation

Last modified 22/04/2025

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7 Procedural Documentation and Coding

Successful pain management practices have implemented processes and procedures that focus on customer service, physician and staff efficiency, and risk reduction which result in optimizing the revenue cycle. The goal is to ensure that all revenue cycle tasks are performed by the right number of people at the right time with the right tools to collect timely and optimal revenue. The revenue cycle, or the process of getting paid, begins with the patient entering a pain management practice and ends with collection of all collectable dollars associated with the services provided to that patient. Every employee and provider in the practice, from the person who answers phones to the pain management professional, has an important role to play in the revenue cycle.

Revenue cycle processes can be divided into two types as shown in Table 7-1—the processes performed on the front-end and the processes performed on the back-end. Front-end processes are those that typically are performed with patient involvement, whereas back-end processes are performed without the patient’s involvement or presence. The accuracy of patient information and timely completion of front-end processes drives the success of the back-end processes to ultimately achieve revenue optimization.

Table 7-1 The Front-End and Back-End Revenue Cycle Processes

Front-End Processes	Back-End Processes
Appointment scheduling and pre-registration	Claim/statement production
Insurance verification and referral management	Payment processing and analysis
Check-in	Denials management
Patient encounter	Accounts receivable follow-up
Test/procedure coordination
Check-out

Front-End Processes

Front-end processes in the revenue cycle include appointment scheduling and preregistration, insurance verification and referral management, check-in, the patient encounter (where coding and documentation occur), test/procedure coordination, and check-out.

Appointment Scheduling

Appointment scheduling is typically the practice’s first encounter with the patient and is one of the most critical steps in the revenue cycle. Future third-party billings and collections efforts depend on the quality of the data obtained at this time. Therefore, it is imperative that accurate and complete patient demographic and insurance information be obtained. The appointment scheduling process includes, but may not be limited to, the following tasks:

• Obtain all patient demographic and referring provider information and enter into the practice management information system (PMIS); this is called preregistration

• Re-register all established patients (e.g., verify or update previously obtained demographic and insurance information)

• Make the appointment, hopefully within patient’s desired time frame

• Inform the patient of practice’s financial policies including collection of co-payment at the point of service (POS),

• Refer the patient to the practice’s website (if one is available) to download a map, health history form, other patient education materials

• Coordinate or make a reminder phone call to the patient about the appointment and financial policies

Successful practices obtain patient demographic information directly from the patient, rather than from the referring physician’s office, to ensure accuracy. Practices that are business savvy offer on their website the ability to make an appointment and provide preregistration demographic and insurance information.

Insurance Verification

Insurance verification and referral management can be a separate process, depending on the size of the pain management practice, or it can be performed at the time of appointment scheduling. Practices obtain required managed care referrals and verify the patient’s insurance eligibility and benefits prior to all new patient appointments to ensure appropriate collections on the back-end. Successful practices will re-verify insurance benefits on all established patients not in a postoperative global period. All too often a practice finds that a patient, new or established, does not have the insurance coverage he or she claims to have and the practice ultimately is not paid for rendered services.

Validation of insurance eligibility and benefits as well as obtainment of referrals for pain management services may be done electronically through on-line capabilities with many payors. It is not always necessary to have this task performed via telephone call requiring staff time. The on-line capabilities come in various formats, such as accessing information directly from a payor’s on-line database or through the PMIS vendor who might perform “batch” (for a group of patients) or “on demand” (for an individual patient) eligibility and benefits verification for the practice.

In summary, the goal of the first two steps in the revenue cycle is to gather and verify patient demographic and insurance information prior to the appointment to provide an optimal opportunity to assess the financial risk, verify insurance eligibility, and obtain proper referrals to ensure appropriate revenue collection when the service is provided.

Check-In

The receptionist plays an important role in the revenue cycle process by validating the patient’s identity and the previously obtained insurance information, as well as collecting any mandatory copayment. Tasks required at the check-in phase of the revenue cycle include, but are not limited to:

• Marking the patient as “arrived” in the PMIS so the system “looks for,” or reconciles, a corresponding charge for the service provided

• Scanning the patient’s insurance card into the PMIS (or photocopying for the paper chart)

• Validating the patient’s identity by comparing the name on the insurance card to the name on a government-issued photo identification card to the patient’s actual identity

• Obtaining required signatures on practice forms or electronic documents (e.g., consent to treat, information release) and communicating the projected patient financial responsibility for the service

• Collecting any insurance company mandated co-payment, entering this action in the PMIS, and providing a system-generated receipt to the patient

It is imperative that co-payments be collected at the point-of-service because this is the point at which the patient’s motivation to pay is greatest and the cost of collections is lowest.

Patient Encounter

The pain management provider renders a service in the office (e.g., evaluation and management code, radiology code) or a procedural service (e.g., injection code, surgery code) and is responsible for documenting and coding the service so accurate billing can occur. Coding for, and documentation of, services performed is best performed by the rendering provider because these are critical components of the revenue cycle. Coding is typically performed on a paper charge ticket, also called an encounter form, or may be done electronically through the PMIS.

CPT Codes

Current procedural terminology (CPT) is a set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers. Each procedure or service is identified with a five-digit code. The CPT manual is updated annually by the American Medical Association (AMA) and the pain management professional specialty societies contribute to CPT code development and maintenance. There are extensive service and procedure coding requirements published in the CPT manual. Providers are responsible for knowing how to accurately report, and document, CPT codes for the services rendered.

There are three categories of CPT codes. Category I CPT codes describe a procedure or service identified with a five-digit numeric CPT code and descriptor nomenclature; these are considered the “usual” CPT codes and are widely accepted by third party payors.

Category II codes, five-digit codes with four numbers and ending with the letter “F”, are intended to facilitate data collection on positive health outcomes and quality patient care. Category III codes, five-digit codes with four numbers but ending with the letter “T”, facilitate data collection on and assessment of, new services and procedures and are used to report procedures that do not have a Category I code. Payors require a valid Category I and/or Category III code(s) for payment consideration. The various types of CPT codes are listed in Table 7-2 with a notation of the application to the pain management specialty.

Table 7-2 Types of CPT Codes ^∗ and Application to Pain Management

Category I CPT Codes
CPT Code Number	Type of CPT Code	Application for Pain Management
00100-01999, 99100-99140	Anesthesiology	Codes describe administration of anesthesia during procedures (generally surgery CPT codes) performed by another provider/physician
10021-69990	Surgery	Includes codes for injections, placement of pain pumps, and other pain management diagnostic and therapeutic services
70010-79999	Radiology (including nuclear medicine and diagnostic ultrasound)	Includes fluoroscopic guidance and localization of needle or catheter tip for pain management procedures as well as diagnostic radiologic procedures
80047-89356	Pathology and laboratory	These codes are generally not used by pain management providers
90281-99199, 99500-99607	Medicine (except anesthesiology)	Includes nerve conduction and electromyography diagnostic testing codes
99201-99499	Evaluation and management	Includes codes for office visits, consultations, and hospital visits used by pain management providers
Category II CPT Codes
0001F-7025F	These codes are supplemental tracking codes that can be used for performance management. They are intended to facilitate data collection about quality of care rendered; the use of these codes is optional.	Includes codes for oncologic pain management as well as assessment and examination of back pain
Category III CPT Codes
0016T-0196T	These codes are used to report temporary codes for emerging technology, services, and procedures and are used instead of an unlisted Category I CPT code (e.g., 64999).	Includes code for percutaneous intradiscal annuloplasty

∗ As per CPT 2009.

ICD-9-CM Codes

ICD-9-CM codes classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. These three, four, and five digit diagnosis codes are used to support, or justify, the CPT codes reported by providers. ICD-9-CM codes are published by the World Health Organization (WHO), whereas the annual coordination and maintenance process is jointly controlled by two branches of the United States government—the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS).

Audits comparing code(s) selected by pain management providers to the documentation should be performed on a regular basis to ensure compliance with third party payor and AMA guidelines. Regular audits and coding education are important components to a practice’s revenue and compliance success.

Test/Procedure Coordination

Many pain management practice patients will require further diagnostic testing and/or diagnostic or therapeutic procedures after seeing a pain management professional. Third party payors often require precertification for testing, such as radiologic procedures, including plain films, magnetic resonance imaging (MRI), and CAT (computerized axial tomography) scans. Successful practices will incorporate this precertification need into the revenue cycle process, particularly if the practice has the capabilities of performing the imaging service. Imaging services performed, and billed, by a pain management professional require the production of a radiologic interpretation report which must be separate from the office visit documentation.

Procedural services, such as injections and surgical procedures, also may require precertification prior to performance of the procedure. The procedure coordinator’s duties include, but are not limited to:

• Reverification of insurance eligibility if significant time has passed since the previous insurance eligibility verification

• Precertification and specific third party benefits information for the service (some payors allow this to be performed on-line)

• Scheduling necessary preprocedure or preadmission testing

• Scheduling the procedure in the designated facility (e.g., ambulatory surgery center, hospital)

• Presurgical financial counseling and collection of a procedure deposit to include the projected patient financial responsibility calculated after obtaining third party benefits information

• Procedure/surgery charge entry (or this may be done on the back-end)

• Reconciling the procedure scheduling log to ensure all charges are received from the rendering pain management professional

Check-Out

After the office encounter is complete, successful practices have incorporated at the point-of-service the task of collecting from the patient any estimated co-insurance, unmet deductible, as well as any previously unpaid balance. Alternatively, previously unpaid balances may be collected during the check-in process. Like collection of co-payments at check-in, collecting patient-responsible portions of the service charge will result in optimal collections and a reduction in expense for patient statement production.

Additional duties performed at check-out include, but are not limited to:

• Scheduling follow-up appointment to avoid delayed follow-up or accessibility problems

• Checking for unanswered questions and additional service opportunities

• Checking service to ensure the patient’s experience was good

• Posting charges for the service(s) rendered as well as any payments and generating a receipt from the PMIS

• Reconciling “arrived” patients to provider completed charge tickets/encounter forms received to ensure a charge is received for each patient seen that session

The best time to collect from a patient is at the point-of-service on the front-end where there is direct patient contact.

Back-End Processes

Back-end processes in the revenue cycle include claim/statement production, payment processing and analysis, claim denials management, and accounts receivable follow-up.

Claim and Statement Production

Professional claims to third party payors can be sent electronically or on paper (also known as hard copy) using a CMS 1500 health insurance claim form. Successful practices submit accurate electronic claims on a daily basis to as many payors as possible; some payors, such as many worker’s compensation plans, require paper claims. Payors tend to process electronic claims in a more timely manner, which helps pain management practices improve cash flow and keep the accounts receivable low.

Table 7-3 includes seven very important tips for successful claim submission. The goal is to submit only once a “clean” claim, meaning one without errors or omissions, and be paid in a timely manner.

Table 7-3 Tips for Successful Claim Submission

• Enter the patient’s name as it appears on the insurance benefits card. Watch for patients using their middle name as a first name and be sure to enter initials.

• Enter patient or payor identification numbers with proper prefixes and/or suffixes.

• Correlate CPT code(s), in box 24D, to the corporate ICD-9-CM code(s) listed in box 21 on the claim form.

• Report CPT codes in descending value order—the highest listed first.

• Enter bilateral procedures, using modifier 50, either on one line (called the “bundled” format) or on two lines (“line-item” format) as noted below. Check with payors for format preference of bilateral procedures to ensure appropriate reimbursement.

• Bundled format Line-item format

• 64475-50 1 unit Double fee 64475 1 unit Single fee

• 64475-50 1 unit Single fee

• List the name and national provider identification number (NPI) of the provider requesting the consultation in boxes 17, 17A, and 17B of the CMS 1500 health insurance claim form.

• Generally box 23 is used for referral, authorization, or precertification numbers, although some plans may use box 19 instead. Check with individual payors for preference.

Practices typically send third party payor claims to a clearinghouse for review, or “scrubbing”, to ensure the demographic, insurance, and code information is appropriate prior to the claim being sent to the insurance company. The edit report, or list of errors noted on the submitted claim, received by the practice must be rectified on a daily basis.