This article discuses neurosurgery billing and pain management billing, as well as spine and pain management coding issues.


For successful spine and pain management coding, the most important thing is for the coder to be familiar with the anatomy and the code set.  A coder must understand the spine anatomy in order to be a successful coder for spine/neurosurgery billing.  The coder needs to understand what approach the doctor is doing, proper level assignment when assigning level for injections, specifically medial branch blocks, facet joints, or RFA’s based on those nerves that are being treated.  And then correctly assign CPTs and ICD-10s.


Being familiar with anatomy is so important for successful pain management billing because with medial branch blocks and facet joint injections, there is a C8 nerve, which then for the spine anatomy pushes down everything to a different level.  Many times we have difficulty with operative notes because the level and the nerve are not accurately documented.


As an example of how important it is to obtain accurate and detailed documentation for pain management billing, we have seen cases where the header of the note states a left laterality and then as we get into the body of the note there is a description of procedure and it is bilateral.  It is important for compliance that all sections of the note are consistent and that there are no discrepancies between the procedure heading and the actual description.  Additionally, you may be leaving revenue on the table if you’re not accurately reporting what procedures were performed.


If at any time there is a question regarding the documentation a good pain management coder would know to go back to the provider to get that clarification or additional information so that the documentation includes all of the levels that are being performed.


One of the biggest spine neurosurgery billing documentation challenges that we’ve found is decompression documentation specifying levels versus nerves.  Documentation for decompression should indicate the specific nerves being decompressed at that level.  For example if they’re doing an L4-L5 decompression are they decompressing both the exiting and the traversing nerve root.  If they are the provider should specifically state this because then one can bill two levels of decompression compared to just having decompressed L4-L5, which would only permit billing for one level of decompression, because they’re not specifically telling the carrier that the provider has done two separate nerve decompressions at that level.  This is a very common problem because frequently the physicians assume that if they say L4-L5 they will get reimbursed for two levels of decompression.  However, it is billed by the nerves decompressed and not by the amount of bone work that has been done.  An example of proper decompression documentation adequately describes this position decompressing the nerves and at which levels, e.g. L3 L4 and L5, that each nerve was decompressed bilaterally around the pedicles and into the foramen.   This is spectacular because you can bill for three levels of decompression for this sample note, whereas if it had only documented decompression of L3-L4 and L4-L5, you could only bill for two levels of decompression.


Some vendors pressure physicians about billing for particular procedures.  An example is where the vendor is stating that a provider will be reimbursed at a certain level if the procedure is coded the way they suggest i.e. CPT 24347 for approximate $1,400, instead of an unlisted 24999 that is likely to reimburse $0.  The challenge is that vendors are not only coding experts, but they are not subject to the compliance requirements to which the provider is liable.  Great care must be taken to ensure that the documentation and the procedure performed are actually meeting what the specific requirements for that CPT code to be reported.  Many vendors are looking to sell their products and are informing the providers that they can bill with certain CPT codes that are not accurate.  We see this frequently where a salesperson will come into a physician or surgery center and make claims about the enormous reimbursement associated with their particular technology or new device and then recommend specific codes.  They will often present pro forma and financial analysis that incredible financial reimbursement in the in their marketing materials.  It can be extremely enticing to think about all of the potential revenue that may come from these new procedures.  Many providers have been caught where they may not have checked with their revenue cycle management team to determine the veracity of these claims and then got burned.  Others have consulted with their pain management billing company and find out that those codes are not appropriate, or that they are untested and speculative and that this might them to risk for insurance take backs in the future.  It is important to make sure that everything that the implant companies are claiming has been thoroughly vetted with respect to coding and compliance.  Having been personally on both sides of this (I personally was the manager of a large business unit for a Fortune Global 20 medical device company), I am confident there is not negative intent on the part of the device companies and they believe these codes are appropriate, but they are not qualified to make those determinations and are frequently incorrect.  Make sure to get supporting documentation from all parties and that they are citing legitimate sources to back up their coding determinations.  There are resources including CPT Assistant where questions are submitted and the AMA will give feedback on the appropriate code to be used.  Your pain management coders and pain management billing company can assist you with determining if these claims by vendors are accurate.

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