Pain management in orthopaedic practices
Increasingly, pain management specialists—physical medicine and rehabilitation specialists or anesthesiologists—are joining orthopaedic groups that have adopted a more global approach to musculoskeletal system care. However, this presents challenges for the billing time, particularly with respect to coding procedures and transfers of care from the orthopaedists to their pain colleagues. The coding team at KarenZupko & Associates shared the following frequently asked questions.

Q: If the orthopaedic surgeon (Dr. Ortho) sees a new patient and determines that the patient needs to see a pain management specialist (Dr. Pain or Dr. Anesthesia), do we code a new patient visit for Dr. Ortho and an established patient visit for Dr. Pain? A: Typically, orthopaedists and anesthesiologists or pain medicine specialists do not share the same specialty code, even if they are part of the same group practice. Dr. Pain or Dr. Anesthesia could report a new patient visit for a referred patient, even if the visit occurs on the same day. The rule is that physicians or providers in different specialties within the same group can bill a new patient visit for the same new patient, even if they share the same tax identification number. Q: My group has a policy that orthopaedic surgeons deal with patients' postoperative pain for 6 weeks and then the patients are referred to the group's pain specialist who manages all ongoing pain. Can the pain specialist bill for these evaluation and management (E/M) visits as a different specialist even though the patient is in the global period? A: Postoperative pain management is included in the global for 90 days. If it is the group's policy for a pain physician to see all postoperative patients, this will most likely be seen as part of the global package and not separately billable, even though a physician of a different specialty is providing the pain management. Attempting to bill for E/M visits to the pain management specialist would constitute high-risk coding. Q: A colleague informed me that billing an office visit every time I give a patient an injection can lead to an audit. I also read a recent article about an orthopaedic practice that had to pay back millions of dollars partially for this reason. I typically bill an established patient visit when I provide an injection, but I always add a -25 modifier to the visit. Does that make me safe from an audit? A: Unfortunately, no. It is true that an E/M or office visit can be reported with a minor procedure such as an injection, but only if the E/M is significant, separate, and exceeds the “preservice evaluation” that is inherent to the injection. Every minor procedure code includes time for a preservice evaluation. This preservice evaluation can be considered a mini-E/M. Medicare and other payers have become concerned that E/M codes are being routinely reported with minor procedure codes without considering whether the extent of the visit was truly more than the preservice evaluation already included in the procedure code. Table 1 shows the preevaluation times (the mini E/M portion) for common in-office injection procedures. Before you report an office visit or E/M code with a minor procedure code such as an injection, ask yourself: “What have I done that goes 'above and beyond' the mini-E/M service that is included in that procedure code? And, does my documentation support that additional work and effort?” Q: When my physician assistant (PA) performs joint injections, can we report those services under the incident-to billing rules? A: If the PA scope of practice regulations in your state allow PAs to perform joint injections, the determining factor is whether the incident-to billing rules are met. If you previously set the plan of care for joint injections, they could be reported as incident-to. If the PA independently made the decision to perform the injection, it should be reported as a direct service. Q: If I see a patient whose MRI findings confirm a traumatic right ACL tear (sprain) (S83.511A), should I report additional codes to describe the symptoms of knee pain, swelling, or difficulty walking? A: No, signs and symptoms that are associated routinely with a disease or injury should not be assigned additional codes unless you are instructed to do so by the classification. Karen Zupko is president of KarenZupko & Associates, Inc. The firm partners with AAOS to deliver annual regional coding workshops in orthopaedics and pain; the next workshop is May 13, in Oakbrook, Ill.