Good/bad reimbursement news for pain management

HCFA deletes some procedures from ASC list

Whether your same-day surgery program is home to a comprehensive pain clinic or simply has an anesthesiology staff who incorporate the latest pain management techniques into their overall practice, current changes could affect the financial picture of your pain management service.

The biggest changes will be noticed by freestanding centers, says Eric Zimmerman, JD, associate with McDermott, Will, and Emery in Washington, DC, which represents the American Association of Ambulatory Surgery Centers in San Diego.

"When HCFA [the Health Care Financing Administration] published the ambulatory surgery center [ASC] proposed prospective payment system regulation in July 1998, nine pain management procedures were deleted, and another five proposed additions were rejected," he says.

The deleted procedures, CPT codes 64420 to 644623, were injections that were determined to be no-surgical and suitable for administration within a physicians’ office setting, he explains.

"There will be no facility fee paid for these injections if they are performed within an ambulatory surgery center if the rules are published as they are today," says Zimmerman. The ASC prospective payment system is expected to be published in early 2001 with implementation likely in January 2002.

"Hospital-based ambulatory surgery programs and pain management programs will most likely notice an increase in the number of pain management patients who require injections since hospitals are permitted to perform the procedures," he says. Although HCFA has determined that those pain management procedures can be performed in a physician’s office rather than an ASC, HCFA is under no mandate to develop a list of approved hospital services, he says. That means the physicians who don’t want to perform a potentially risky procedure in their offices can decide to use the hospital and they will be reimbursed, explains Zimmerman.

"These injections are inherently risky procedures that can cause convulsions, cardiac arrhythmia, and paralysis," he says. The physician is also invading a sterile space near the brain, so there is also a risk of infection, Zimmerman adds.

"If a physician performs the procedure in an office, there is a need for a crash cart, pulse oximeter, and other monitoring equipment normally found in an ASC setting," he says.

Reimbursement for pain management services in the hospital outpatient prospective payment system can be helpful to hospital-based programs, says Devona J. Slater, CMCP, president of Auditing for Compliance and Education, a consulting firm in Leawood, KS, that specializes in coding and billing compliance issues for anesthesia and pain management. "Bills for pain management procedures are now procedure-driven rather than cost-driven, making the coding process simpler and more accurate." Pain management procedures can still be a revenue generator for hospitals, even though overall reimbursements for pain management were reduced, she adds.

"We have to remember that many pain management procedures are so new that there are not CPT codes to accurately reflect the services that were provided," Slater says. "How the system handles those procedures that do not have codes is yet to be seen." For example, some techniques that were reimbursed for as much as $800 are now reimbursed at levels around $200, but you are allowed to bill for every procedure that is done, she says. "The important thing to remember is to attribute actual costs on the pain center to actual revenue generated by the pain center."

While he still keeps an eye on what is happening with the outpatient prospective payment system, Gene Hybner, administrator of Bay Area Surgery in Corpus Christ, TX, doesn’t expect that changes will significantly affect his financial picture for the pain management service.

"About 60% of our pain management patients are workers’ compensation cases," he explains. "We are lucky in Texas because the state workers’ compensation program doesn’t differentiate between hospitals and ambulatory surgery centers, so we get paid 85% of the charges we bill for each patient, just like the hospitals receive," he says. Medicare patients represent about 7% of his pain management caseload, and the other 33% are third-party payers or self-pay.

Hybner is proactive when working with third-party payers. "We negotiate payments for pain management upfront with the payers with whom we have contracts, and we encourage them to look at outcomes," he says.

Hybner’s staff call all pain patients the day after the procedure to see how they’re doing and include the results of the call in the chart. Because many pain management patients receive two to three injections over a three- to six-week period, their charts include information from several follow-up calls. A clear picture of how the treatments work emerges from the documentation, he says. 

For more information about pain management reimbursement, contact:

Gene Hybner, Administrator, Bay Area Surgery, 7101 S. Padre Island Drive, Corpus Christi, TX 78412. Telephone: (361) 985-3500. Fax: (361) 761-3754. E-mail:

Devona J. Slater, CMCP, President, Auditing for Compliance and Education, 10308 State Line Road, Leawood, KS 66206. Telephone: (913) 648-8572. Fax: (913) 381-1180. Web:

Eric Zimmerman, JD, Associate, McDermott, Will and Emery, 600 13th St. N.W., Washington, DC 20005. Telephone: (202) 756-8000. E-mail: