This article is about how to effectively bill for Physical Medicine & Rehabilitation with Intervention Pain management services in an outpatient setting. This article is very useful for Board Certified Physician in Physical Medicine & Rehabilitation, Board Certified Physician in Pain Medicine and Intervention Pain Management practice. If you are the medical biller:

1) First thing, make sure your provider is listed under his correct specialty with the insurances. Remember that Pain Management provider do not necessarily mean they are (PM&R) M.Ds. They can be Anesthesiologists, Chiropractors, Acupuncturists, Massage Therapists, Physical Therapists and Occupational Therapists! Many claims were denied for payments like for CPT code 64480, 64483, 64484, 27096 and all other related procedure codes (you will see on the EOB a "reason code" like this: the provider is not privileged to do the procedure)--- it is because your provider might have been only listed as a Pain Management provider and NOT as PM&R and Pain Medicine medical provider.

(2) In terms of Patients' Benefits, remember that each patient has different Pain Management benefits non-inclusive with PM&R office visits! Some plans do not have pain management benefits!

(3) Make sure you have all the fee schedules assigned to your provider both for outpatient hospital and office procedures. Compare which one allows descent amount based on your billed amount

(4) Claims must be accompanied with medical documentation to support medical necessity (this is very important!). If the insurance requests for documentation, send it right away! So they do not delay processing your claims. If there is a referral or letter of precertification, attach them too!

(5) Procedures like CPT codes 72040, 72020, 72100, 72295, 73542, 76005 done in the hospital, you must use modifier 26 (professional component only, the medical equipments are from the facility or the hospital). Normally, this is with location code 22 (Outpatient Hospital). If the procedure is done in the office, do not use modifier 26. Instead use location code 11 without a modifier.

(6) Procedures done bilateral use modifier 50.

(7) If the provider performed an office procedure like CPT Code 64405, 20552, 20553 and sees the patient for office consultation on the same day, use modifier 25 for consultation CPT code.

(8) In terms with the insurance companies, which pays more? to which CPT procedure code? I think procedures done for Workers' Compensation and "No-Fault" patients allows higher based on the billed amount compared to all other insurance companies.

(9) Take note: Workers Comp and No Fault patients ALWAYS needs precertification/preauthorization for procedures to be done either in an outpatient hospital or office.

(10) Generally, it is always a safer side to check on your patients' benefits and eligibility before you render the service or do the procedure.

(11) And if you are a provider's office, make sure you choose the best medical billing service that will submit your claims on a timely manner. Highly knowledgeable with HIPAA and with your specialty in terms of processing your claims both electronic and paper submission. Of course, you also have the option to purchase the best medical billing/accounting software that is cost-effective and won't hurt your overhead expenses!