Pain Management Billing Services Insights on Medical Necessity Edits

Pain management claims can pass all the checks and appear accurate at face value but still end up failing payer review. In such cases, it is often seen that the procedure could be accurate, the code reflects the process correctly and the required authorization may be on file. Yet, payment could stop because the claim fails to satisfy a key component before adjudication.

While an in-house team might see this as nothing more than a hassle, a pain management billing company sees this as something more than isolated billing errors. Only the most capable billers use this as a sign to understand the internal problem that led to such a situation. As a result, fixing the problem at a fundamental level.

Follow along to see how professional pain management billing services can help providers with medical necessity edits.

What Are Medical Necessity Edits?

Before understanding how pain management billing services help providers in this aspect, it is important to understand what medical necessity edits entail. Medical necessity edits screen claim information against applicable coverage criteria. Depending on the issue, the payer may also need clinical records to determine whether the service meets those criteria.

Medical necessity edits are not at all similar to asking the clinician if they think the treatment is appropriate. This is more technical in nature, as it is where every clinician determines the appropriate treatment for the patient registered and so the clinical record should explain the treatment rationale and provide the information needed for that assessment.

Meanwhile, the payer applies the mandated coverage rules and automated claim logic to understand the financial feasibility of the claim line. These two assessments can reach different outcomes if the record fails to clearly reiterate how the clinical side of things meets the coverage criteria of the payer.

With the introduction of AI and automation, there are many systems that can do all these without any sort of human intervention. However, this part of pain management billing is a nuanced area. Therefore, being too dependent on automated systems can be detrimental and dangerous.

Related Reading: Pain Management Billing Errors That Quietly Drain Revenue

Why Pain Management Claims Face Close Review

It is quite common for pain practices to combine different service lines such as in-office evaluation, image guided injections, ablations, medication management, implanted devices, etc. Furthermore, each of these episodes comes with its own regulatory nuances that a provider needs to understand.

This sense of complexity can create areas where a claim can easily drift away from the realm of the payer’s coverage. If an authorization identifies a specific spinal level before the treatment, and the operative documents another, then there could lead to detailing gaps. In other words, opening up the billing department for additional work.

This is why most pain management billing services and billing guidance see symptoms, functional limitation, unsuccessful conservative care, diagnostic findings, treatment goals, and response to prior therapy as central documentation to refer.

Common Medical Necessity Edit Triggers

Medical necessity edits do not materialize from thin air. Instead, they are a product of disconnect between different pain management RCM points. Here are some of the more common reasons that trigger medical necessity edits:

Diagnosis and Procedure Do Not Align

The most common cause could be a clear disconnect between the performed procedure and diagnosis. Therefore, it is of paramount importance that the submitted diagnosis must clearly explain why a certain intervention was performed. A broad usage of pain codes might accurately describe the patient’s condition, but it cannot establish the relationship between the procedure and the coverage.

This should also not lead coders to choose a code that is covered by the respective payer’s policy. This is an unethical practice and can lead to a lot of flak. Therefore, it is advisable that the provider simultaneously record procedure details as the medical journey continues from one stage to another.

Another way to handle this is with the help of clear prebilling review questions such as:

• Is the diagnosis documented?
• Does it support the procedure and the treated anatomical requirement?
• Does it satisfy the applicable payer policy?

If the answer to these questions is uncertain, then the claim might need clarification before it is submitted. Therefore, helping the pain management billing services to churn out cleaner and more payable claims.

Conservative Treatment is Poorly Documented

Another common trigger is a poorly documented conservative treatment. In pain management, some interventions also require documentation of an adequate trial of conservative treatment, unless the applicable policy recognizes an exception, such as intolerance. This is why a short note only states the failure of a conservative process, instead of explaining the cause is inadequate.

The record needs to be comprehensive and must record every detail about the conservative process, like the patient response, medication threshold, and other such details. If the details are missing, the newer procedure might not be valid for payment. This is why it is important for the pain biller to be as detailed as possible, as that dictates payout.

Related Reading: The Essential Guide to Pain Management Billing You Need to Read

Frequency and Repeat-Procedure Limits are Exceeded

A repeat-service edit on the other hand, examines more than the overall number of performed procedures. Payers also ask for evidence regarding the pre and post-procedure state of the patient. Whether the service provided meaningful relief or not.

This is especially relevant for patients who move between different locations and providers. If the billing team fails to produce concrete details about the past procedures, then the staff may unknowingly exceed a frequency threshold of a specific service line.

This is why it is advisable for providers to adopt a payer-aware utilization tracker. This can help providers keep tabs on frequency-based service lines effectively and without any form of hassle.

Procedure Details are Incomplete

Pain management documentation is known to be technically intensive. This means that the clinical record must contain the procedure-specific details needed to support accurate coding and payer review and it depends on the process. Here, the recorded details often include medical approaches, region of spine affected and laterality level, imaging use, total number of treated areas, administered medication, and the findings.

Minor inconsistencies in these details can trigger edits and therefore, it is important that providers record procedure details as comprehensively as possible. Therefore, if a claim indicates a bilateral service, but the note only describes one side, then there can be some gaps. This can eventually lead to financial escalations or reworking.

How SunKnowledge can make a difference here?

The thing about medical necessity edits is that they do not begin at the claim submission. In fact, they begin much earlier when benefits are checked, procedure is scheduled, authorization is requested, and so on. Therefore, by the time the denial reaches the A/R department, the original gap could be weeks old.

Therefore, providers need to onboard capable pain management billing services that understand the finer nuances of pain management billing. This is where our professional billers at SunKnowledge can come in handy.

Our billers not only understand the importance of medical necessity edits but offer complete support for all your billing needs. And the best part is that we offer all of these at a flat fee of just $7 an hour. Hence, making us affordable and capable at the same time.