Medicare Billing for Chronic Pain Management: Best Practices and Guidelines

Chronic pain is one of the most severe health issues in the United States, costing the country billions of dollars in lost work time and productivity, as well as a lower quality of life. It is estimated that between 11% and 40% of persons in the United States suffer from chronic pain. As pain medicine specialists focus on providing patient-centered and coordinated care, they must also deal with growing insurance company scrutiny, expanding prior authorization requirements, changing codes, fee schedule decreases, and more patient financial responsibility. Let’s have a glimpse of the best practices and guidelines for chronic pain management billing:

Best Practices for Chronic Pain Management Billing:

  • Stay Updated:

When submitting medical claims for chronic pain management, practices must use the correct codes and follow the proper rules. Applying Medicare standards to all payers is a fundamental blunder that practices can make. As Medicare and private payer reporting criteria differ, practices must remain up-to-date. Private payers may have different requirements for globals, coverage, bundling, and modifier usage than Medicare. Payment policies and provider guides are available on private payer websites. The Medicare Claims Processing Manual, National Coverage Determinations (NCDs), and Local Coverage Determinations (LCDs) are all available on the CMS website.

  • Verify insurance coverage and benefits:

It is critical to verify the patient’s insurance coverage and benefits before the date of service to avoid denials and receive payment for services. Before giving treatments, practitioners can use adequate insurance verification services to ensure that the patient’s current coverage details, services are covered, and deductibles are satisfied.

  • Prior authorizations:

To qualify for payment coverage, physicians must acquire advance clearance from a health plan before providing a specific chronic pain management therapy to a patient. For instance, prior authorizations are required for pain drugs and interventional pain procedures. Obtaining these approvals can be a significant headache for chronic pain medicine practitioners and patients, and it is best accomplished with the proper assistance.

Guidelines for Chronic Pain Management Billing:

It is critical for practices to keep up with CPT code revisions. Physicians execute various needle treatments and must understand how to utilize the appropriate codes on claims. Let’s look at some trigger point injection coding:

  • CPT codes 97810 – 97814 are assigned to acupuncture treatments. Beginning January 21, 2020, Medicare will pay for all modalities of acupuncture, including dry needling for chronic low back pain, subject to specific guidelines outlined in National Coverage Determination (NCD) 30.3.3.
  • There are guidelines for coding trigger point injections as well as tendon sheath, ganglion cyst, ligament, carpal, and tarsal tunnel injections. Code 20552 is for injections of one or two muscle groups, whereas code 20553 is for injections of three or more muscle groups. Per session, only one of these codes can be billed.
  • Regardless of the number of injections at any particular site or the number of sites, the number of services for each code is one.
  • Other trigger point injection codes are:
  1. 20560 and/or 20561, dry needling
  2. 20550, injection(s); ligament, tendon sheath
  3. 20551, tendon origin/insertion
  4. 28899 (unilateral procedure, toe or foot)
  • You must bill trigger point injections on only one line, irrespective of the number sites. Multiple injections at the same place per day are regarded as one injection and should be coded with one unit of service (NOS 001).

Similarly, there are numerous codes for ligament, tendon sheath, carpal, ganglion cyst, and tarsal tunnel injections. In addition, providers must utilize the correct ICD-10 codes to reflect diagnosis. There are extensive ICD-10 instructions on how to report various types of pain and the code sequencing procedure.

For 2023, CMS has proposed new HCPCS codes and valuation for chronic pain management and treatment services (CPM). That’s why there is a need to look for chronic pain management services.

But what to Look for in Chronic Pain Management Billing Services!

Are you looking for accurate and timely chronic pain management billing services?

If yes, then you should ensure the presence of the following aspects:

  • Your claims should be handled by dedicated processing professionals who are familiar with the chronic pain management laws of workers’ compensation, no-fault, and other payers.
  • Most delayed and refused claims are due to coding errors – a chronic pain management billing professional should understand and be competent in applying the particular coding of chronic pain treatment.
  • Payer pre-authorizations must be acquired and kept on file unless each treatment necessitates a new authorization. One of the most significant benefits of hiring a competent chronic pain management billing service is having a medical billing agency that understands and works closely with a range of payers and is familiar with their specific requirements.
  • A good chronic pain management billing company should also provide additional services to help you supervise your revenue cycle, such as changes and demographics in patients and enrollments, A/R management for patients and insurance, account analysis to learn payer patterns and where your practice may be “leaking” money from unpaid but payable claims and other sources.

24/7 Medical Billing Services has been assisting practices and facilities of all sizes and specialties with their chronic pain management billing and coding services as a pioneer in the medical billing and claims management sector. To learn more about how we can ensure that your pain management and other types of claims are invoiced accurately, regardless of payer, contact us at +1 888-502-0537 or email us at

See also: Hospital Revenue Cycle: Trends In Billing And Collection Services


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