A diagnosis for the cause of a patient’s pain isn’t always possible, and pain treatment varies widely from physician to physician. These two traits make pain management unique among medical specialties, which can make pain management coding uniquely challenging.
But one thing remains true for all specialties — the right code can mean a substantial difference in reimbursement. That’s why we’ve asked Chris Boucher, our resident pain management coding expert, to help you prevent reporting errors from siphoning off your hard-earned pay.
Read on for pain-free guidance to navigate a few common-but-costly pain management coding scenarios.
After a level-three evaluation and management (E/M) service for a new patient, the provider performs a two-view radiologic examination of a patient’s entire spine (anteroposterior and lateral). I reported 72010 for the radiologic exam and received a denial. What did I do wrong?
Answer: Your coding would have been correct a few years ago, but the code you reported for the exam — 72010 (Radiologic examination, spine, entire, survey study, anteroposterior and lateral) — is no longer in service.
The correct coding for your scenario would be:
Your mistake sounds like it might be the product of using outdated CPT® resources. According to the Spine and Pelvis Subset of the Radiology Section in CPT® 2019, “72010 has been deleted. To report, use 72082.”
This illustrates the kind of risk you run by using outdated CPT® resources. If you choose an outdated code, and have no access to new resources, it’s going to be a tough slog to run down the correct code. Though it’s a pricey annual expense, you really should have new versions of CPT®, ICD-10, and HCPCS each year.
My provider performed a level-three evaluation and management (E/M) service for an established patient with a torn rotator cuff. What’s the correct ICD-10 code?
Answer: You’ll need to know whether the tear was nontraumatic or traumatic before you can add the correct ICD-10 code to your 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) claim.
Nontraumatic: If the notes do not mention that the cuff tear was traumatic, then you’ll choose from one of the following code sets, depending on encounter specifics:
6th character needed: Whichever diagnosis code you choose from the above list, you’ll need to include a sixth character to indicate laterality.
Traumatic: If notes specify that the tear was traumatic, you’ll choose one of the codes from the S46.01 — (Strain of muscle(s) and tendon(s) of the rotator cuff of shoulder) family, depending on encounter specifics.
7th character needed: For traumatic rotator cuff tears, you’ll also need a seventh character to indicate the type of visit, along with the sixth character for laterality.
An established patient with trigeminal neuralgia reported to our physician complaining of facial pain. After a level-three E/M service, the physician performed destruction of the trigeminal nerve. How should I report this encounter?
Answer: Your final code choice will depend on which branch of the trigeminal nerve the physician destroyed. Go back to check the encounter notes and then choose one of the following codes depending on encounter specifics:
Regardless of which code you choose, you’ll append G50.0 (Trigeminal neuralgia) to the procedure code to represent the patient’s condition.
Also use G50.0 with 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity … ) for the E/M service. Attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99213 to show that the E/M and nerve destruction were significant, separately identifiable services.
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The Coders’ Specialty Guide 2019: Pain Management includes all CPT® and HCPCS codes relevant to pain management, simple descriptions that explain each code, expert advice for assigning codes, Medicare reimbursement details, diagnosis codes crosswalk, applicable modifiers, CCI edits, global days, code index, hundreds of anatomical illustrations, and more.
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