Apache Health as a leading medical billing analytics company often gets questions about specific billing issues from our clients and prospective clients.  This article looks at some of the issues faced in pain management billing with respect to Medicare Local Coverage Determinations (LCD’s), National Coverage Determinations (NCD’s), and other commercial payer policies.


This subject can be very confusing and we are often asked how often the insurers’ billing policies are updated.  We know that some of them are updated annually, but remember that annually by code means that it changes every day.  Something is changing all the time.  Just because you hear that a payer policy is being updated annually doesn’t mean you only have to look at that payer only once a year.  It just means that that particular service is being reviewed and then they could have another one the next day and the next day.  Providers need to figure out a way to stay on top of all of these changes or have a strong medical billing partner who does this for them.  A lot of the software systems will have the LCDs and NCD’s embedded within them, but the commercial payer policies can be very difficult and require significant resource to consistently and frequently monitor their written policies and research any potential changes that may not have been published.


The payer policies are diagnosis driven and typically list ICD-10 codes that will meet medical necessity based on the CPT code.  Although for pain management billing medical necessity also means frequency of injections.  Are the providers following these guidelines?  If they’re performing too many injections in a given time frame the claims may be denied.  Progress of treatment must be included in the operative note.  Additionally, sometimes the insurance company’s policies might even contradict what is deemed medically necessary within their own policy.  Good communication between the ambulatory surgery center and the physicians is also very important.  For example for carrier policy requirements to support medical necessity especially in the spine and pain management billing arena, does the provider document three to six months of conservative treatment?  Do they have specific percentages of the pain relief for the previous injection procedures performed?  Was there documentation of physical therapy prior to the procedures?  Are the patients on medication therapy?  Is there documentation of MRI findings?  These requirements are all needed in your operative notes in order to support medical necessity.


Following is an example of a Medicare LCD compared to an example of a commercial payer policy just to demonstrate the difference in pain management billing for a medial branch block which ICD-10 codes are meeting medical necessity:


Procedure Note

Chief Complaint:                              Bilateral neck and head pain

Pre-Operative Diagnosis:              Facet joint pain, cervical/thoracic

Post-Operative Diagnosis:            Facet joint pain, cervical/thoracic

Procedure:                                         Medial branch block




Medicare     Payer Policy  
ICD-10 Code Description   ICD-10 Code Description
M47.011 – M47.016 Anterior spinal artery compression syndromes, occipito-atlanto-axial region – Anterior spinal artery compression syndromes, lumbar region M53.0-M53.1 Cervicocranial – cervicobrachial syndrome [covered for the diagnosis of facet pain with chronic back or neck pain lasting more than 3 months despite appropriate conservative treatment – not for therapy]
M47.1 Vertebral artery compression syndromes, occipito-atlanto-axial region M53.81-M53.83 Other specified dorsopathies [cervical region][ covered for the diagnosis of facet pain with chronic back or neck pain lasting more than 3 months despite appropriate conservative treatment – not for therapy]
M47.022 Vertebral artery compression syndromes, cervical region M54.2 Cervicalgia [covered for the diagnosis of facet pain with chronic back or neck pain lasting more than 3 months despite appropriate conservative treatment – not for therapy]
M47.11 Other spondylosis with myelopathy, occipito-atlanto-axial region M54.6 Pain in thoracic spine [covered for the diagnosis of facet pain with chronic back or neck pain lasting more than 3 months despite appropriate conservative treatment – not for therapy]
M47.12 Other spondylosis with myelopathy, cervical region M54.30-M54.5 Sciatica and lumbago [covered for the diagnosis of facet pain with chronic back or neck pain lasting more than 3 months despite appropriate conservative treatment – not for therapy]
M47.13 Other spondylosis with myelopathy, cervicothoracic region
M47.14 Other spondylosis with myelopathy, thoracic region
M47.15 Other spondylosis with myelopathy, thoracolumbar region
M47.16 Other spondylosis with myelopathy, lumbar region
M47.21 – M47.28 Other spondylosis with radiculopathy, occipito-atlanto-axial region – Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811 – M47.818 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region – Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M47.891 – M47.898 Other spondylosis, occipito-atlanto-axial region – Other spondylosis, sacral and sacrococcygeal region
M54.03 – M54.09* Panniculitis affecting regions of neck and back, cervicothoracic region – Panniculitis affecting regions, neck and back, multiple sites in spine
M62.830* Muscle spasm of back
M71.38 Other bursal cyst, other site
Group 1 Medical Necessity ICD-10 Codes*M54.03 thru M54.009 and M62.830* Use for FACET SYNDROME ONLY Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: M54.03 thru M54.009 and M62.830* Use for FACET SYNDROME ONLY


Billing for pain management for a medial branch block, as you can see, the LCD and the payer policy do not match.  Some payers following Medicare guidelines, some payers have a smaller list, while other payers might have a list that is several pages long.  This is a good example of why you can’t use LCD’s across the board for all patients.  Providers need to know the pain management billing rules of each payer, and of course they change all the time.  If the pain management billing processes are not set up well with good documentation of all of the payer policies and with those payer policies implemented into the medical billing system as a set of payer rules, the first thing that most payers are going to do if they see one of these diagnosis codes or a diagnosis code that’s not on their approved list is to request medical records or potentially to flat out deny it.  If you’re a neurosurgeon or pain management provider you have probably seen a substantial increase in the volume of requests for medical records since the implementation of ICD-10.  Remember also that payers are looking for an excuse to deny your claim or at the very least to slow it down by having a legitimate excuse for delay.  Don’t give them one.  If a neurosurgeon is circling an ICD-10 code on a superbill or checking within an EHR it is not always apparent that there are differences in the medical necessity coverage between the payers.  It is a good procedure to pull payer policies and review them at least once a quarter and update billing procedures accordingly.  Across the country we have seen an increase in requests for medical records, which we expect all pain management and neurosurgery billing companies have experienced.  Pain management has been growing rapidly as a specialty and payers have been looking to slow its growth.


About Apache Health

Apache Health is a revenue cycle management (RCM) analytics, benchmarking, and auditing company.  The founders of Apache formerly ran a large RCM company that was acquired by a private equity group in a rollup.  Apache’s predictive analytics will benchmark billing performance and project exactly how much more revenue you should earn from your existing volume of patients. Using many factors and a blend of artificial intelligence and specialty specific benchmarks, the model projects whether changing the billing process would improve collections for your particular mix of procedures and payers.  Apache Health can help you evaluate whether to outsource the billing, determine which billing company to select to maximize performance, or track in-house billing performance improvement over time. For more information contact:

Sean McSweeney

Apache Health