The American Academy of Pain Medicine

Coding Changes for 2008

In This Article:

• ICD-9-CM Changes
• CPT-4 Changes
• Medical Team Conferences (99366-99368)
• Non-Face-To-Face Physician Services

2008 Coding Changes – What You Need to Know

By Emily Hill, PA

The new and revised ICD-9-CM and CPT-4 codes for 2008 have been released. This means it’s time to review and make changes to your charge capture forms, your EHR (electronic health record) and any “cheat sheets” used in the practice.  Your reimbursement depends on you and your staff being aware of the changes and understanding how to report new and revised codes.

As you prepare for the changes, remember to read the complete code descriptors and any associated instructions in the code books.  Both the CPT-4 and ICD-9 codebooks contain helpful information to assist you in the proper use of the codes.  This information is sometimes revised to clarify existing instructions or to communicate new guidelines. Changes in text are identified in CPT-4 by using green print and placing the symbol ►◄around the text.  ICD-9-CM uses bold print and italics to distinguish changes in the guidelines section of the manual.

There are numerous changes each year in both ICD-9-CM and CPT-4. This article outlines some of the more significant CPT-4 and ICD-9-CM changes for Pain Medicine practices.

ICD-9-CM Changes

Although approximately 150 new codes were added, most will not be used in the typical Pain Medicine practice.  There are two codes in particular that may be helpful in your practice.  These are V68.01 (Disability examination) and V68.09 (other issue of medical certificates).  These codes are under the section “Encounters for administrative purposes”.  Although CPT-4 has included codes for number of years to describe an E/M service for a disability evaluation (99450, 99455, 99456), there has not been a specific corresponding ICD-9-CM code to describe the reason for the encounter.  Previously, V68.0 (Issue of medical certificates) was used to report medical certificates for cause of death, fitness or incapacity.

A summary of all the code changes are located in the front of most versions of the manual.  The changes were effective October 1, 2007 and will be applicable through September 30, 2008. In addition, you can access the codes on the CMS Web site.

The most noteworthy addition for Pain Medicine physicians is the inclusion of guidelines to accompany the section titled, “Pain, not elsewhere classified” (338).  This group of codes was added to ICD-9-CM last year and includes codes for acute, chronic, and neoplasm related pain.  The guidelines clarify that with a few exceptions pain not specified as acute or chronic should not be reported with codes in the 338 category.  The exceptions are post-operative pain, post-thoracotomy pain, neoplasm pain, and central pain syndrome.

Likewise, the codes from the sub-category 338.1(acute pain) and 338.2 (chronic pain) should not be assigned if the underlying definitive diagnosis is known.  The exception is when the encounter is for pain control or pain management rather than the treatment of the underlying condition. Thus, pain medicine physicians can appropriately report these codes for their pain management services.

The guidelines further address the use of these codes as a principal diagnosis.  In general terms, the primary diagnosis is the one chiefly responsible for the service or encounter.  Therefore, when pain control or management is the reason for the encounter, category 338 codes should be reported as the first-listed or principal diagnosis.  The underlying cause of the pain, if known, is listed as an additional diagnosis.  An example is an encounter for pain management for acute neck pain from trauma.  The Pain Medicine physician assigns code 338.11 ( Acute pain due to trauma)  followed by code 723.1
(Cervicalgia) to identify the site of pain. This guideline holds true for neoplastic pain. The pain code is the primary diagnosis and the neoplasm is listed as the secondary one.

When a procedure, such as insertion of a neurostimulator is performed for pain control, then the appropriate pain code should be reported.  In contrast, when the encounter is for a procedure directed at treatment of the underlying condition, then the appropriate condition code should be reported and a code from the 338 category is not reported.  In most cases, the latter situation does not apply to Pain Medicine physicians as there is often another physician addressing the underlying condition responsible for the patient’s pain.

In some circumstances, it may be appropriate to report both a category 338 code and a code identifying the site of pain.  For example, if a code describes the site of pain but does not fully describe whether the pain is acute or chronic, then both codes may be reported.  In the case of most pain medicine services, the code in the 338 category is listed first and the site of pain code listed next.

Other clarifications include the use of the 338 codes in the postoperative period.  The guidelines state the 338 codes for postoperative pain should not be reported for “routine or expected postoperative pain immediately after surgery”.  It also notes there is no time frame defining when pain becomes chronic.  The physician’s clinical documentation guides the use of the codes classified to subcategory 338.2 (chronic pain).  Chronic pain syndrome is identified as 338.4.  This should only be used when the condition is specifically documented in the clinical record.

ICD 2008 Pain Codes
 
338.0 Central pain syndrome 
338.1 Acute pain 
            338.11Acute pain due to trauma 
            338.12Acute post-thoracotomy pain 
            338.18Other acute postoperative pain 
            338.19Other acute pain 
338.2 Chronic pain 
            338.21Chronic pain due to trauma
            338.22Chronic post-thoracotomy pain 
            338.28Other chronic postoperative pain 
            338.29Other chronic pain 
338.3 Neoplasm related pain (acute) (chronic) 
338.4 Chronic pain syndrome

The full set of guidelines is found in the front of the ICD-9-CM manual in the section titled, “ICD-9-CM Official Guidelines For Coding and Reporting”.

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CPT-4 Changes

Although there are not any new CPT codes directly related to Pain Medicine services, there are a number of changes that may be of interest to Pain Medicine physicians and their practices.

Medical Team Conferences (99366-99368)

A new series of team conference codes appear in CPT 2008 and the former codes (99361 and 99362) have been deleted.  The new codes differentiate between conferences at which the patient is present (face-to-face) and those without the patient in attendance (non-face-to-face).  These time-based codes require a minimum of three qualified health professionals from different specialties and/or disciplines.   All members reporting these codes must have performed a face-to-face evaluation within the previous 60 days. Documentation of participation is required by all providers reporting team conference services.

The codes for non-face-to-face services distinguish between those provided by physicians and those of non-physician providers.  Only one code was created for face-to-face team conferences. This code is for the work of non-physician providers only.  CPT instructions state physicians should report the appropriate Evaluation and Management Service (E/M) for the time they participate in face-to-face team conferences rather than a team conference code.

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Non-Face-To-Face Physician Services

CPT created a new sub-section of codes for Non-Face-To-Face E/M services.  A code for “On-Line Medical Evaluation” (99444) was created.  The code is reported for each episode of care within a 7 day period.  Codes for “Telephone Services” (99441-99443) provided by a physician were revised and renumbered.  These codes are time based and applicable only for telephone services requested by an established patient.  Neither the On-Line Medical Evaluation or the Telephone Services codes can be reported if the patient has been seen by the physician within the last 7 days or if an appointment is made for the next available urgent visit appointment.  The creation of these codes does not guarantee payment.  Physicians should carefully read the CPT guidelines and instructions applicable to these codes prior to reporting these services.

CPT Modifiers

CPT editorially revised certain modifiers (22, 25, 51, 58, 59, 76, 78) to eliminate redundancy, inconsistency, and variable interpretations identified by users of CPT.  The changes are meant to clarify modifier usage and not to revise the original intended use of these modifiers.  The changes to modifiers 22, 25 and 59 may be of most interest to Pain Medicine physicians.

The title for Modifier 22 was revised to identify increased procedural services.  Previously the title used the phrase “unusual procedural service”.  The language was also modified to reflect the requirement that “substantially greater services than typically provided” must be performed in order to append the 22 modifier to more difficult procedural services.  The language also emphasizes the need to clearly document the substantial, additional work and the reason for the additional work (i.e. increased intensity, time, technical difficulties, severity of patient’s condition, physical and mental effort required).

Modifiers 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service ) and 59 (Distinct Procedural Service ) were revised to make clear that modifier 25 can only be appended to  E/M codes and modifier 59 only appended to non-E/M codes.  It also reiterates that modifier 25 is the appropriate modifier to use when separate and distinct E/M services and non-E/M services are performed on the same day.

Remember, CPT-4 code changes are effective January 1, 2008.  It is important that you and your practice staff review all the changes in CPT to determine if there are other changes impacting your practice.  Appendix B of the CPT manual includes a Summary of Additions, Deletions, and Revisions.  Don’t forget to check the modifier section for the revisions to the modifiers noted above and to read carefully all code descriptors and applicable guidelines and instructions.  Proper coding helps ensure appropriate reimbursement and reduces audit liability.

Common Pain Medicine CPT® Codes

Effective January 1, 2008
Click on above link to access 2008 Common CPT codes for Pain 

(CPT is a registered Trademark of the American Medical Association)
Coding & Reimbursement Committee AAPM

Links

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