ICD-10: History and Context.

In recent months, organized medicine has been consumed by the anticipated transition to the 10th iteration of the International Classification of Disease system. Implementation has come and gone without the disruptive effects predicted by many. Despite the fundamental role the International Classification of Disease system plays in health care delivery and payment policy, few neuroradiologists are familiar with the history of its implementation and implications beyond coding for diseases.

Hydrocodone bitartrate for chronic pain.

Hydrocodone bitartrate is the most commonly used drug for acute and chronic pain in the U.S. with over 135 million prescriptions in 2012. The U.S. is the primary consumer of hydrocodone, using 99% of the global supply for 4.4% of the global population. With its easy availability and abuse patterns, hydrocodone has been touted as a primary driver of opioid-related abuse and misuse. There are no clinical efficacy studies of hydrocodone in short-acting form in combination with acetaminophen or ibuprofen in chronic pain. Hydrocodone has been approved with two long-term formulations since 2014. The FDA has rescheduled hydrocodone from Schedule III to Schedule II which went into effect on October 6, 2014, along with a limit on added acetaminophen of 325 mg for each dose of hydrocodone. This review examines the evolution of hydrocodone into a common and yet controversial drug in the U.S. with its pharmacokinetics, pharmacodynamics, safety and efficacy.

Transforaminal lumbar epidural steroid injections.

Low back pain is an important medical, social, and economic problem involving approximately 15% to 39% of the population. Of the numerous therapeutic interventions available for treatment of chronic low back pain, including surgery, epidural administration of corticosteroids is one such intervention commonly used. Several approaches available to access the lumbar epidural space are the caudal, interlaminar, and transforaminal, also known as nerve root or selective epidural injection. The objective of an epidural steroid injection is to deliver corticosteroid close to the site of pathology, presumably onto an inflamed nerve root. This objective can be achieved by the transforaminal route rather than the caudal or interlaminar routes. Reports of the effectiveness of epidural corticosteroids have varied from 18% to 90%. However, reports of the effectiveness of transforaminal epidural steroids have shown it to be superior, with outcome data indicating cost effectiveness as well as safety. This review describes various aspects of transforaminal epidural steroid injections in managing chronic low back pain.

Recent developments in evaluation and management services.

Evaluation and management services are important aspects of interventional pain management; however, significant confusion continues as to proper coding and documentation in this field. In addition, recent developments in the area of evaluation and management services over the last few months are of significance to interventional pain physicians. Two major developments in the year 2000 include a warning from the Health Care Financing Administration (HCFA) with regards to misused codes, and issue of new draft evaluation and management guidelines to improve physician acceptance by simplification. The HCFA has sent letters to all physicians in the United States on June 1, 2000, with information that it will be focusing this year on two current procedural terminology (CPT) codes used to report evaluation and management services - 99214 and 99233. The HCFA contends that these codes accounted for a significant portion of coding errors in the last two audits and that documentation for many of these services was found to be sufficient only to support services more appropriately described by CPT codes 99212 and 99231 resulting in downcoding by two levels by HCFA and implying that physicians are upcoding by two levels. The second issue relates to the release of yet another version of the new draft evaluation and management guidelines by HCFA in June 2000. These were preceded by an article by the administrator of HCFA, Nancy-Ann Min DeParle, which was published in JAMA. The new guidelines are purported to eliminate "bullets" and "shading"; reduce the need for counting the "elements"; introduce the first specialty-specific vignettes; and include a nationwide study of the new proposed guidelines.

Current issues in billing and coding in interventional pain medicine.

Interventional pain management is a dynamic field with changes occurring on a daily basis, not only with technology but also with regulations that have a substantial financial impact on practices. Regulations are imposed not only by the federal government and other regulatory agencies, and also by a multitude of other payors, state governments and medical boards. Documentation of medical necessity with coding that correlates with multiple components of the patient's medical record, operative report, and billing statement is extremely important. Numerous changes which have occurred in the practice of interventional pain management in the new millennium continue to impact the financial viability of interventional pain practices along with patient access to these services. Thus, while complying with regulations of billing, coding and proper, effective, and ethical practice of pain management, it is also essential for physicians to understand financial aspects and the impact of various practice patterns. This article provides guidelines which are meant to provide practical considerations for billing and coding of interventional techniques in the management of chronic pain based on the current state of the art and science of interventional pain management. Hence, these guidelines do not constitute inflexible treatment, coding, billing or documentation recommendations. It is expected that a provider will establish a plan of care on a case-by-case basis taking into account an individual patient's medical condition, personal needs, and preferences, along with physician's experience and in a similar manner, billing and coding practices will be developed. Based on an individual patient's needs, treatment, billing and coding, different from what is outlined here is not only warranted but essential.

Correct coding in interventional pain management.

The National Correct Coding Council (NCCC) was created by the Health Care Financing Administration (HCFA) in 1996 to help ensure that providers across various jurisdictions receive like payment for the same services, use the same codes and provide similar documentation for services performed. The Correct Coding Initiative (CCI) was a direct outgrowth of the NCCC's, the purpose of which was to identify and isolate inappropriate coding, unbundling, and other irregularities in coding. To avoid inappropriate or incorrect coding and billing in interventional pain management, it is imperative that interventional pain physicians and their staff be familiar with correct coding policies, as well as understand the meaning of Current Procedural Terminology, along with comprehensive codes, component codes, and mutually exclusive codes. This review describes CCI and various correct coding policies specifically relevant to interventional pain medicine. In addition, certain commonly used codes of interventional techniques are also described with implications of comprehensive, component, and mutually exclusive coding terminology.

Evaluation and management service in interventional pain practice: doing it right!

Proper coding and documentation for evaluation and management services continuously and progressively are becoming not only complicated, but also confusing. Although medical evaluation of patients has been a fact of life since the beginnings of medical history, medicine has been substantially influenced by federal regulations since the enactment of Medicare. Physicians' fear of being prosecuted is increasing. This is reinforced by actions of the federal government in multiple cases with sky-high penalties and by the Office of the Inspector General's target of 600,000 physicians in practice in its work plan for the new millennium. Evaluation and management services utilization, medical necessity, and appropriate documentation for level and complexity of service are extremely important components of evaluation and management services. Similarly, differentiating between a consult versus a visit is also crucial to avoid upcoding, or in a worst-case scenario, downcoding. While the history is the same for all types of visits except for the complexity for each level, four types of physical examination are available, either in a general multisystem examination or a single-system examination. However, the complexity of medical decision making is the essential factor in deciding to which level the evaluation and management belong. This review will discuss various aspects of evaluation and management guidelines in interventional practice and also guide the physician in performing these evaluations in an appropriate manner with proper documentation, thus avoiding the pitfalls of fraud and abuse.

Epidemiology of low back pain.

Low back pain is a symptom that cannot be validated by an external standard. It is a disorder with many possible etiologies, occurring in many groups of the population, and with many definitions. Low back pain is a common problem, with a prevalence in the United States ranging from 8% to 56%. It is estimated that 28% experience disabling low back pain sometime during their lives, 14% experience episodes lasting at least 2 weeks, 8% of the entire working population will be disabled in any given year, and the lifetime prevalence of low back pain is 65% to 80%. It is believed that most episodes of low back pain will be short-lived and that 80% to 90% of attacks of low back pain resolve in about 6 weeks, irrespective of the administration or type of treatment. However, multiple studies in the late 90s showed recurrent or chronic low back pain, evaluated at 3 months, 6 months, or 12 months, ranging from 35% to 79%. Risk factors of low back pain are multifactorial, with many possible etiologies. Multiple risk factors of low back pain and lower-extremity pain include physical factors, social demographic characteristics, habits, and psychosocial factors. This review will discuss the epidemiology of low back pain, with emphasis on frequency, causes, and consequences of low back pain; the influence of age, gender, morphologic characteristics, and genetics; and the influence of occupational, mechanical, social, habitual, and psychological factors.

Impairment evaluation in pain management: physician, or attorney in white coat?

Impairment and disability evaluations have become a growth industry in the United States. Impairment evaluation is sometimes termed independent medical evaluation, or IME. So-called independent medical experts are hired guns to provide opposite opinions, similar to attorneys in this case. IME is the practice of medicine on one hand. On the other hand, it is the practice of law in white coats. Impairment is defined as the loss of a physiologic function or of an anatomic structure. Disability, however, is defined as an inability or altered ability to successfully accomplish a given task. For successful implementation of various disability systems, the essential medical/legal interface can be successfully achieved only if the physician has at least a minimum level of understanding of the legal system, and the attorney has an adequate understanding of the medical facts and the limits of medical science. Many physicians approach impairment ratings and disability evaluations by extrapolating from the knowledge and experience gained in their specialties. However, there are numerous fundamental differences between the standard medical evaluation and impairment/disability evaluation. Important aspects of impairment evaluation include medical evaluation, analysis of findings, and comparison of the results. In impairment evaluation, it is crucial to establish causal relationship and decide on maximum medical improvement, apart from providing the impairment rating. This review will discuss various aspects of impairment evaluation.

Appropriate documentation, billing and coding in interventional pain practice.

Appropriate documentation, billing and coding in interventional pain practice is a crucial issue with a wide arena of regulatory reforms. There have been reports of billions of dollars in losses in health care fraud. Office of Inspector General reports a massive war on health fraud. Substantial savings from prepayment audits for Part B in 1999, and continued criminal filings by the Department of Justice indicate persistence of Health Care Financing Administration to combat fraud. In addition President Clinton's initiatives to fight Medicare waste, fraud, and abuse have created increased fear of investigation or prosecution among physicians, leading to changes in their practice patterns. Documentation of medical necessity with coding that correlates with multiple components of the patient's medical record, operative report, and billing statement is important. This review describes the regulatory issues, steps in documentation of medical necessity, appropriate billing and coding, and examples of codes describing CPT 1999 and 2000 for a multitude of procedures. These illustrations and the information provide practical considerations for the use of interventional techniques in the management of chronic pain based on the current state of the art and science of interventional pain management, rules and regulations. However, this article and its descriptions do not constitute legal advice.

CPT 2000: interventional pain management coding in the new millennium.

UNLABELLED: Current Procedural Terminology is a systematic listing and coding of procedures and services performed by physicians and other providers. The CPT is the most widely accepted nomenclature for the reporting of procedures by physicians and other providers for health-care services provided by the government, and private health-insurance programs. It is most widely accepted for claim processing, and for the development of guidelines for medical care review, and it provides the uniform language applicable to medical education, research, and utilization. The CPT 2000 includes a multitude of changes. Those of most important interest to interventional pain management specialists include neural blockade where the codes used in pain management have been totally revamped. The entire section of neural blockade codes has been substantially altered, either by deletion, modification, or addition of a new code. Various deleted codes include 62274 to 62279, 62288, 62289, 62298, and 64440 to 64445. The definitions for CPT codes 62273, 62280, 62281, 62282, 62287, 62291, 62350, 64622, 64623, and 72285 have been modified and changed. Multiple new codes not only include replacement codes for epidurals, but also creation of codes for sacroiliac-joint injection, sacroiliac-joint arthrography, percutaneous lysis of epidural adhesions, facet-joint injections at the cervical and thoracic levels, neurolytic facet-joint neural blockade for cervical and thoracic levels, transforaminal injection codes for cervical/thoracic and lumbar/sacral, epidurography and radiological examination. The several advantages and disadvantages of new codes and future directions in CPT coding are described. KEYWORDS: Interventional pain management, CPT 1999, CPT 2000, epidural injections, facet-joint.

The role of evaluation and management services in pain management.

Evaluation and management services are an integral part of interventional pain management. Health Care Financing Administration "HCFA" and American Medical Association "AMA" promulgate rules and regulations in the evaluation and management arena. Proper understanding and appropriate coding is a crucial part of interventional pain management, as consequences of inappropriate coding and insufficient documentation to support charges billed to Medicare include not only civil monetary penalties, but exclusion from Medicare program and prison terms. Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including the past and present illnesses, examinations, tests, treatments, and outcomes. In essence, proper medical record documentation must provide the information and answer the questions including why?, what?, where?, and when?. Descriptors for the levels of evaluation and management services recognize seven components which include history, physical examination, medical decision making, counseling, coordination or care, nature of the presenting problem, and time spent. Based on the type of history, physical examination, complexity of medical decision making, patient evaluation services are of several types, which include problem focused, expanded problem focused, detailed, comprehensive with moderate complexity, and comprehensive with high complexity. History includes chief complaint; history of present illness; review of systems; and past, family, and/or social history. Similar to the history, physical examination also encompasses four types, which include a problem focused examination, an expanded-problem focused examination, a detailed examination, and a comprehensive examination. This review describes evaluation and management services of new patients, as well as established patients with sample office evaluations.

The impact of national correct coding policy on interventional pain management.

Health Care Financing Administration ("HCFA") created the National Correct Coding Council ("NCCC") to help ensure that providers across various jurisdictions received like payment for the same services and use the same codes and provide similar documentation for services performed. As a direct out growth of NCCC's work, HCFA established the National Correct Coding Policy in 1996 and eventually implemented the Medicare "Correct Coding Initiative" to identify and isolate inappropriate coding, unbundling, and other irregularities in coding. To appropriately implement National Correct Coding Policy in interventional pain management an interventional pain management specialist and their staff must be familiar with correct coding policies as well as understand the physicians current procedural terminology (CPT, medical surgical practice and packages, modifiers, separate procedures, comprehensive and component services, incorrect coding/unbundling and various specific issues relevant to practice of interventional pain management) Comprehensive codes include certain defined services that are separately identifiable by other codes known as component codes. Because component codes are captured by comprehensive codes they man not be listed separately when the complete procedure is done. For example, in interventional pain management, 62279, which is continuous lumbar epidural, is considered a comprehensive code. Various component codes include 62270, 62272 - 62274, 62276 - 62278, 62288 and 62289, among others. This review describes National Correct Coding Policy, correct procedural terminology, medical and surgical practice and packages, evaluation and management services along with description of most codes used in interventional pain management with correcting coding edits for comprehensive codes and for mutually exclusive codes.

Neural blockade in cervical pain syndromes.

Chronic neck pain, headache, and arm pain are some of the most common patient complaints confronting today's health care provider. Chronic neck pain is reported to be a frequency symptom in 34% of the general population with 14% of the general population reporting neck pain that lasted for more than 6 months. The magnitude of the problem is demonstrated by increase of cervical spine surgery by 45% and cervical fusion by 70% over a ten year period from 1979 through 1988. Therapeutic effectiveness of a large variety of interventions in managing chronic neck pain is inconclusive. Pain and dysfunction have been attributed to a number of structure in the neck which have a potential for producing a pain pattern in the neck, head, and upper extremity which include intervertebral disc, nerve roots, facet joints, and ligamentous and muscular structures. Neural blockade in the cervical spine, though introduced in 1912, lagged behind that of the lumbar spine. At the present time, neural blockade is an extremely popular tool for diagnostic purposes in evaluation of neck pain, even though it has not developed a definitive role in the management of chronic neck pain and associated syndromes. The object of this review is to focus on various aspects of neural blockade in the management of chronic neck pain and associated syndromes including its rationale, clinical effectiveness, indications, and complications.

Role of correct coding for interventional techniques.

There has been enormous emphasis on the description and definition of what the physician does for and to the patient, with fraud and abuse evolving as an important aspect of interventional pain medicine. Compliance with the laws and regulations encompassing documentation with coding, billing, and collections, and medical records, is crucial in today's interventional pain medicine practices. The Health Insurance Portability and Accountability Act of 1996, provided the Office of Inspector General and the Federal Bureau of Investigations with broad powers and directed them to identify and prosecute health-care fraud and abuse. The National Correct Coding Council was created by Centers for Medicare and Medicaid Services to help ensure that providers across various jurisdictions receive like payments for the same services, use the same codes and provide similar documentation for services performed. As a direct outgrowth of the National Correct Coding Council's work, the Centers for Medicare and Medicaid Services established the National Correct Coding Policy in 1996 and eventually implemented the Correct Coding Initiative (CCI) to identify and isolate inappropriate coding, unbundling, and other irregularities in coding. Multiple versions of National Correct Coding Policies have been released in the form of National Correct Coding manuals ranging from version 5.0 to 7.2. This review discusses various aspects of correct coding in interventional pain medicine.

Percutaneous lysis of epidural adhesions.

Percutaneous epidural adhesiolysis, lysis of epidural adhesions, percutaneous neuroplasty, or epidural neurolysis is an interventional pain management technique which emerged during the latter part of the 1980s. It is becoming established as a common treatment modality in managing chronic low back pain that is nonresponsive to other modalities of treatment. While epidural adhesions most commonly result following surgical intervention of the spine, leakage of disc material into the epidural space following an annular tear, or an inflammatory response can also result in the formation of epidural adhesions. Even though advanced technology, including computerized tomography and magnetic resonance imaging, have made significant advances in the diagnosis of epidural fibrosis, it is believed that epidural adhesions are best diagnosed by performing an epidurogram. Percutaneous lysis of epidural scar tissue, followed by the injection of hypertonic saline neurolysis, has been shown to be cost effective in multiple studies. This review discusses various aspects of percutaneous nonendoscopic adhesiolysis and hypertonic saline neurolysis including clinical effectiveness, complications, rationale, and indications.

Spinal endoscopy and lysis of epidural adhesions in the management of chronic low back pain.

Spinal endoscopy with epidural adhesiolysis is an interventional pain management technique which emerged during the 1990s. It is an invasive but important treatment modality in managing chronic low back pain that is nonresponsive to other modalities of treatment, including percutaneous spring guided adhesiolysis and transforaminal epidural injections. While epidural adhesions most commonly result following surgical intervention of the spine, leakage of disc material into the epidural space following an anular tear, or an inflammatory response can also result in their formation. Even though advanced technology, including computerized tomography and magnetic resonance imaging,have made significant advances in the diagnosis of epidural fibrosis, it is believed that epidural adhesions resulting in chronic persistent pain are poorly managed. Percutaneous endoscopic lysis of epidural scar tissue has been shown to be cost effective and a safe modality. This review discusses various aspects of endoscopic adhesiolysis, including clinical effectiveness, complications, rationale, and indications.

The role of guidelines in interventional pain medicine: let us separate apples and oranges.

Practice guidelines are not only an ancient tradition, but they are a fact of life. The first guidelines were developed in the 1840s, shortly after the use of anesthesia was first demonstrated. Even though practice guideline development has spawned an impressive and over-aggressive literature of its own, many unanswered questions exist with regard not only to practice parameters and guidelines in general, but in particular with the application of interventional techniques in managing persistent pain. In spite of the great potential of clinical practice guidelines, and the involvement of numerous medical societies and physician groups, there is still a great debate within the profession not only about the pros and cons of the development and usage of the guidelines, but also conflicting and controversial opinions on both sides of the issue, i.e., providers and patients vs payors. This article discusses the development, usage, advantages, disadvantages and the implications of practice guidelines to interventional pain medicine specialists.

The inability of the clinical picture to characterize pain from facet joints.

Facet joints, as a source of low back pain, have attracted considerable attention and been a source of controversy in recent years. Significant progress has been made in precision diagnosis of chronic low back pain with neural blockade. In the face of less than optimal diagnostic information offered by imaging and neurophysiologic studies, and in the face of mounting evidence showing lack of correlation between clinical features, physical findings, and diagnosis of facet joint mediated pain, controversial features have been described to validate the assumption of facet joint mediated pain by set criteria. The prevalence of lumbar facet joint mediated pain in patients with chronic low back pain has been established in this study as 42% using controlled comparative local anesthetic diagnostic blocks, with a false positive rate of 37%. The evaluation of role of various clinical features described in the literature, six features showed negative correlation with facet joint mediated pain. However, these six feature involved only a small number of patients. In conclusion, facet joint mediated pain is a common entity in patients suffering with chronic low back pain nonresponsive to conservative care, who present to a nonuniversity pain management practice. However, the history, clinical features, and radiological features are of no significance or assistance in making the diagnosis of facet joint mediated pain with certainty.

Interventional techniques in the management of chronic pain: Part 1.0.

The practice guidelines for interventional techniques in the management of chronic pain are systematically developed statements to assist practitioner and patient decisions about appropriate health care related to chronic pain. These guidelines are professionally derived recommendations for practices in the diagnosis and treatment of chronic or persistent pain. They were developed utilizing a combination of evidence and consensus to improve quality of care, increase patient access,improve patient outcomes, improve appropriateness of care, improve efficiency and effectiveness, and achieve cost containment. Included in the guidelines is a discussion of their purpose,rationale, importance, and methodology, and patient population, pathophysiologic basis, and various interventional techniques utilized in the management of chronic pain including rationale, outcomes, and cost effectiveness. They also describe the role of diagnostic blocks and therapeutic blocks with suggested algorithms for interventional techniques in the management of conservative care of chronic pain.