Chronic Pain Update: New Rules for 2016

-->January 15, 2016Billing & Compliance Alerts


    by Justin Vaughn


    For those of you who are chronic pain physicians, or whose anesthesia group includes a chronic pain component, the following will act to summarize the notable changes in the rules and regulations for 2016.



    Medicare Conversion Factor.  There was a slight decrease in Medicare’s conversion factor (CF), from $35.9335 to $35.8279.  The CF reflects the price Medicare pays for a relative value unit (RVU) in the Medicare Physician Fee Schedule (MPFS).

    Professional Fees for Primary Procedures.  Physicians will see a nearly negligible increase—but increase nonetheless—in Medicare payments for their standard chronic pain procedures (eg, facets, ESIs, SIJs, trigger points, etc.) in 2016, regardless of the place of service. Reimbursement for kyphoplasty and vertebroplasty will be slightly better, at 5% or more increase.


    Urine Drug Testing.  The most significant change in reimbursement for chronic pain practitioners in 2016 involves urine drug testing (UDT).  Payment for these services were severely slashed according to one healthcare attorney, with many labs reporting a 70% reduction in Medicare reimbursement.  This service is detailed a bit more in the section immediately below.


    Overhaul of UDT Coding.  Medicare has completely revamped UDT coding for 2016.  All of Medicare’s previous UDT “G-codes” were deleted, including the entire panoply of codes Medicare had just adopted for 2015.  Replacing these nearly 30 codes is a scaled-down set of only 7 codes, as noted below:

    • New Screening Codes:

    G0477 – Test read by direct optical observation, such as dipsticks, cups, cards, and cartridges.  This code pays $14.86 (unadjusted for geographic locality), and is billed once per date of service, regardless of how many drug classes are tested.  This code bundles sample validation codes, such as for pH, creatinine, etc.

    G0478 – Test read by instrument assisted direct optical observation. This code pays $19.81, and is billed once per date of service, regardless of how many drug classes are tested.  Sample validation services are bundled.

    G0479 – Test read by chemistry analyzers, such as immunoassay and enzyme assay.  This code pays $79.25, and is billed once per date of service, regardless of how many drug classes are tested.  Sample validation services are bundled.

    • New Confirmation Codes:

    The four new confirmation codes are defined the same, with the only difference being how many drug classes are tested.  The more drug classes tested, the higher the Medicare reimbursement.  For example, all 4 confirmation codes are defined as requiring sophisticated testing equipment such as LC/MS and GC/MS, which are able to identify individual drugs and distinguish between structural isomers.  Each of the 4 codes bundles specimen validity tests, and each excludes immunoassays and enzyme assays (eg, desktop analyzers).  The number of tests required for each code and the reimbursement for each code is as follows:

    G0480 – 1-7 drug classes, including metabolites, which pays $79.94

    G0481 – 8-14 drug classes, including metabolites, which pays $122.99

    G0482 – 15-21 drug classes, including metabolites, which pays $166.03

    G0483 – 22 or more drug classes, including metabolites, which pays $215.23

    Medicare continues its refusal to recognize or reimburse the AMA’s new presumptive and definitive UDT codes that were adopted in CPT 2015.

    New E&M Codes for Advanced Care Planning.  Last year, the AMA created 2 new codes for advanced care planning:  99497 and 99498; however, Medicare did not list those codes as “active” at that time, and did not pay for them.  For 2016, these 2 codes have been assigned an “active code” status, and are now separately payable under the MPFS.


    Identifying the Billing Physician.  The 2016 MPFS Final Rule clarifies that the billing physician is the one directly supervising the service, even though he/she may not be the initial or “usual” physician.  The Final Rule states:

    . . . the physician or other practitioner who bills for the incident to service must also be the physician or other practitioner who directly supervises the service. 

    The Rule further clarifies that:

    . . . where the supervising practitioner is not the same as the referring, ordering or treating practitioner, only the supervising practitioner may bill Medicare for the incident to service.

    Excluded Personnel Cannot be Billed as Incident To.  The Final Rule also prohibits billing incident to for services performed by auxiliary personnel who have been excluded from federal programs, or who have had their enrollment revoked for any reason.


    The major changes affecting chronic pain in the 2016 CPT manual are as follows:

    Facet Neurolytics.  The AMA, via CPT instructions, now clarifies that facet neurolytic procedures are coded “per joint, not per nerve.”  Additionally, the AMA advises that a facet neurolytic of T12-L1 should be coded as thoracic (64633), not lumbar.  Finally, the AMA cautions that facet destruction codes should not be reported for either pulsed radiofrequency (RF) or any RF procedure where the temperature is less than 80 degrees, Celsius (i.e., low grade RF).

    SIJ Neurolytics.  The CPT manual for 2016 contains the following clarification relative to sacroiliac joint (SIJ) nerve destruction:  “For destruction by neurolytic agent, individual nerves, sacroiliac joint, use 64640.”

    Previously, many pain practitioners would submit SIJ neurolytics using a facet destruction code relating to L5-S1.  According to this new instruction, nerves which are denervated relative to the SIJ are now captured by 64640, other peripheral nerve or branch.

    Stim Analysis and Programming.  The 2015 descriptor for code 95972, stimulator programming and analysis up to one hour, has been revised in 2016 to excise the “one hour” verbiage.  It now applies regardless of how much time is involved.  Not surprisingly, CPT 95973, each additional 30 minutes of programming, has been deleted.

    Spinal Accessory Block.  The 2016 CPT manual has deleted 64412 because Medicare found an inordinate amount of incorrect coding relative to spinal accessory blocks.  Instead, the AMA now instructs providers to bill this procedure using CPT 64999.

    Prolonged E&Ms by Supervised Staff.  Although this may have little application in the typical pain practice, the AMA added codes 99415 (additional 45-74 minutes of face-to-face patient time by clinical staff) and 99416 (each additional 30 minutes) for incident to billing of services by clinical staff such as RN’s, LPN’s, or MA’s (excludes NP’s or PA’s, who have their own separate codes).  The time does not have to be continuous, but can be discontinuous.  The prolonged E&M codes are billed in addition to the normal E&M code billed.  For example, assume the usual 99213 visit is billed, which typically requires 15 minutes.  If clinical staff spends an extra 45 minutes face-to-face with the patient, in addition to the 15 minutes referenced in 99213, the physician can bill 99213 and 99415 to account for 60 minutes of clinical staff face-to-face time, assuming the physician is in the office and immediately available. These codes are limited to the office or outpatient settings.



    Orthotics.  The Office of Inspector General (OIG) has opened 2 new inquiries concerning orthotics payments.  The first inquiry will center on the amount of money Medicare is spending on orthotics. The second will focus on the medical necessity of orthotics.  The OIG reminds providers that each of the DME MACs have local coverage determinations (LCDs) that provide a narrow window of clinical indications justifying medical necessity for orthotics, as well as documentation requirements for the Detailed Written Order (DWO) and the Proof of Delivery (POD).  Each provider needs to ensure that all 3 of these components, i.e., clinical indications, DWO, and POD, are correctly documented—especially in light of coming audits of these services.

    Prolonged Services.  The OIG will start auditing prolonged service E/M codes to see if they are medically necessary.  The healthcare watchdog agency has stated that these add-on service codes should be “rare and unusual.”

    Illegal Immigrants.  Medicare does not authorize payment for medical services to individuals who are here illegally.  However, Medicare contractors (MACs) have been doing a poor job in patrolling this.  The OIG notes that MACs have doled out $91.6 million in improper payments for medical services to illegals, and the OIG will now start to recoup those payments.



    Individual Measures.  Whether reporting via claims or through a “traditional” registry, the 2016 MPFS Final Rule confirms you must report at least 9 measures, covering at least 3 of the national quality strategy (NQS) domains, for at least 50% of the applicable Medicare claims.  Of the measures reported, at least 1 must be a “cross-cutting” (CC) measure.  If you report less than 9 measures or less than 3 NQSs, you will need to rely on the measure applicability validation (MAV) process to save you from the 2% penalty adjustment on 2018 Medicare claims.  This process evaluates whether you could have reported more measures than you did.  If MAV determines the number of measures you submitted was satisfactory, given your practice parameters, then you will escape the PQRS penalty.

    New Chronic Pain Measures.  There are 3 new opioid-related measures—all of which are reportable via a registry only:

    #408 – Opioid Therapy Follow-up Eval

    #412 – Signed Opioid Treatment Agreement

    #414 – Interview for Risk of Opioid Misuse

    New Cross-Cutting Measures.  There are 3 new CC measures for 2016:

    #431 – Unhealthy Alcohol Use (reportable via registry and measures groups)

    #112 – Breast Cancer Screening (reportable via claims and registry)

    #154 – Falls: Risk Assessment (reportable via claims and registry).

    Measures Groups.  For those opting to report via traditional registry, there is a new measures group available for 2016 that could conceivably be used by pain practices:  “Preventive Care Measures Group,” which contains the following measures:

    #39 – Screening for Osteoporosis for Women Aged 65 – 85 Years of Age

    #48 – Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

    #110 – Preventive Care and Screening: Influenza Immunization

    #111 – Pneumonia Vaccination Status for Older Adults

    #112 – Breast Cancer Screening

    #113 – Colorectal Cancer Screening

    #128 – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

    #134 – Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

    #226 – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    #431 – Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling


    If you go with the measures groups option (which can only be done via a registry), you must report on 20 patients, the majority of which must be Medicare beneficiaries.  Whatever reporting or measure options you choose, be sure to communicate that information to your Medac team at your earliest opportunity.



    The 2016 value‐based payment modifier (VM) program contains a couple of notable changes, as outlined below.


    Eligible Participants. Along with all physicians, certain non‐physician practitioners (NPPs) will come under the VM program. These NPPs are nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs).


    VM Penalty.  The “VM penalty” will apply where less than 50% of the group(which may include a combination of physicians and the above‐listed NPPs) successfully reports PQRS in 2016. The penalty (reflecting a percentage reduction in Medicare reimbursement in 2018) is to be based on a three‐track model for program‐eligible providers:


    • 4% ‐ Groups of 10 or more
    • 2% ‐ Groups of less than 10
    • 2% ‐ Groups of ANY size consisting exclusively of NPPs (eg, CRNA‐only group)


    Quality Tiering.  Another potential source of payment reduction (or bonus) comes in the form of the quality tiering (QT) component of the VM program. While the VM penalty, discussed above, is based on whether or not your group was generally successful in reporting PQRS measures, the QT component seeks to grade you based on which PQRS code, per measure, you typically submitted. This is the part of the VM program that puts into motion the “pay for performance” doctrine. If the PQRS codes you submitted tend to indicate you were clinically competent (as CMS would define that term), then you may receive a bonus. If, on the other hand, you consistently report a PQRS code indicating non-performance of the measure, then you are more likely to be hit with a QT penalty. Here is how the QT carrot and stick approach shakes out:


    • The Maximum Bonus [multiple of an upward payment adjustment “factor” (“x” ‐ to be later determined) and based on an analysis of clinical quality AND cost containment]


    4x ‐ Groups of 10 or more

    2x ‐ Groups of less than 10

    2x ‐ Groups of ANY size consisting only of NPPs


    • The Maximum Penalty (percentage reduction in Medicare reimbursement to be determined by analyzing clinical quality AND cost containment)


    4% ‐ Groups of 10 or more

    2% ‐ Groups of less than 10

    0% ‐ Groups of ANY size consisting only of NPPs


    Of special note, if the group incurs the VM penalty, no QT analysis will be performed and thus no QT penalty will be applied.


    I wish to thank chronic pain compliance attorney David Vaughn of Baton Rouge, La. for providing the research on which much of the above was based.


    •  MEDAC – Committed to Continuing Client Education  •


    The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author’s presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.