Perioperative Pain Management: Billing for New Procedures

Published on October 15, 2019

Advances in perioperative pain management can mean more efficient, safer postoperative pain management for patients, but new procedures can pose billing challenges for providers.  Newly developed procedures most often don’t have an appropriate code designated in CPT.  If there is no appropriate CPT code for a procedure, coders are directed to use the unlisted code from the section. However, this can cause problems with filing claims electronically, many clearing houses reject unlisted when submitted as is.  How can a provider be reimbursed for services if the claim won’t go through to the payer?

 The trick is to learn how to bypass those edits in billing software that can cause a clearing house to reject an unlisted code.  To bill for unlisted services, it is important to include a description of what is being done.  The unlisted code’s description is vague and does not describe what is being done.  Therefore, adding a description of the procedure to the code before filing the claim is required. Depending on the billing software being used, this can be done, usually at an administrative level. 

One fairly new procedure being done now is the quadratus lumborum block.  There is no code for this procedure.  The description “quadratus lumborum block” can be added to the unlisted code before filing the claim.  This tells the payer what procedure is being performed.  Additionally, providers should choose an existing procedure which is similar in work and complexity, to gauge a reasonable fee.

Getting the claim through the clearing house to the payer is only the first step.  Most payers will initially deny a claim for an unlisted procedure code, requesting medical records for review.  An appeal can then be submitted including a description of the procedure and any other supporting documents.  When performing any procedure, it is important to document the details clearly and thoroughly.  This will help support the claim on appeal and can ultimately be the deciding factor as to whether a claim is reimbursed or denied.

Obtaining reimbursement for new procedures is challenging, but not impossible.  Sending a description with the unlisted code and appealing with medical records can and most often do yield positive results. 

 

By Heather E. Golfos, CPC, CANPC

Coding Department Manager