Prevent Interventional Pain Denials and Improve Payments

StreamlineMD is here to provide interventional pain management documentation tips to prevent denials and improve payments.  With continuous declines in physician payments, every detail counts.

  • Update your report templates/macros.
  • Ensure that your documentation is clear and concise, and consistent with CPT 2024 code language.

Why Insurance Carriers Deny Claims:

Insurance carriers’ business model is to collect premiums quickly and pay out claims slowly. Insurance carriers’ revenue is generated by holding onto premiums as long as possible and investing this money to get returns that translate to revenue.

Denying claims, especially those that are high dollar, is an easy way for insurance carriers to slow down claim payment, or to not pay claims at all.  In fact, insurance carriers actively use internal algorithms and AI to automate claim denials.

How Coders and Billers Respond to Claim Denials:

Claims are denied for various reasons. Some common reasons include lack of medical necessity, lack of prior authorization, and procedure bundling. This article’s focus is mainly on denials due to lack of medical necessity.

Your coding and billing team must watch for claims denials, review them quickly, gather necessary supporting documentation including the provider’s documentation, and appeal these denied claims for payment.

How to Prevent Claim Denials and Improve Payments:

  • Remember that your documentation is reviewed by multiple stakeholders: referring physicians, insurance carriers, coders, and billers.
  • Your documentation is typically the key ingredient to preventing, and successfully appealing, denied claims.
  • Your documentation must clearly state what was performed and why. It does no good to appeal denied claims with faulty or substandard documentation.
  • When documentation is at its best, insurance carriers have fewer reasons to deny and stall payment.
  • Documentation best practices can decrease denials and increase payment turnaround times, which is more important than ever due to latest CMS payment reductions in 2024.

Top Reasons for Interventional Pain Claim Denials:

Interventional pain coding is complex, especially when the report does not contain specific language identifying the exact target site of therapy, the agent utilized, imaging guidance and medical necessity. There are various CMS MAC policies. CMS has LCDs (Local Coverage Determination) which include the CPT and ICD-10 diagnosis coverage. CMS also has LCAs (Local Carrier Advisory) which provide guidance on coding and billing practices but do not establish coverage policies. Most other insurance companies have their own policies which may or may not follow CMS.

1. Accuracy of Documentation

There are several distinct types of therapeutic interventional pain codes located in the 20000, 60000, 90000 and Category 3 sections of the CPT book. Methods include injections, infusions, and different types of ablations; heat, cryo and laser. Some codes are inclusive of imaging guidance, others may be coded separately. A permanent image must always be saved when billing  for imaging services.

20000 series include:

  • Tendon injections sheath and tendon insertion site(s), 20550-20553.
  • Joint Aspiration and/or Injections, 20600-20611.

60000 and Category 3 series include:

  • Interlaminar, Epidural and Subarachnoid Injections, 62320-62327, +0777T.
  • Somatic and Sympathetic Nerve Blocks, 64400-64489.
  • Facet Joint Injections, 64490-64495 and 0213T-0218T.
  • Radiofrequency (non-pulsed) Ablations of Facet Joints, 64633-64636.
  • Radiofrequency (pulsed) Ablations of Facet Joints, Unlisted CPT 64999, and RSI code by modality.
  • Cryoablation of Nerves, 0440T-0402T include imaging guidance.

90000 series include:

  • Chemotherapy Administration into CNS (Intrathecal, includes spinal puncture), 96450. This code is used for Spinraza Injections. Imaging guidance is separately billable for this procedure.
  • If the radiologist obtains access with fluoro guidance and pushes the drug, 96450 + 77003 are billed.
  • If two different providers: Radiologist obtains intrathecal access with imaging guidance and a different specialist pushes the drug, the radiologist will bill 62270 and (FL, CT, US). The provider pushing the drug will bill 96450.


  • Report templates should include CPT language simplified to ensure correct pre-authorization, coding, and ease of appealing reports when denied. State the approach, device/method, and the exact anatomical site(s) of device placement to deliver the therapy.
  • Document interlaminar, epidural, or subarachnoid needle placement and when used, real-time pressure sensing epidural guidance system utilization.
    • Medial branch nerves are not always named for the transverse process they cross, but rather for their originating somatic nerve location. Typically, each lumbar facet joint level is innervated by a medial branch nerve from the vertebra above and below (L3/L4 facet level is innervated by the L2 & L3 medial branch nerves).
  • Describe localizing the target area with imaging guidance. An exam header, i.e., “Ultrasound guidance” does not adequately support billing for imaging guidance services. Some pain management codes are inclusive of imaging guidance, others are not. If the documentation is in the report, coders will bill separately when allowable. If imaging guidance was not used or an image was not saved (equipment failure or human error), document it in the report to avoid billing for imaging without a saved image.
  • These report recommendations will also enhance AI learning for faster billing and reimbursement turnaround times.

2. Meeting Individual Payer Policy Requirements

There are numerous different CMS and third-party policies for interventional pain procedures by each CPT category above. It is particularly important to review payer policies once quarterly for specific details on CPTs, ICD10 diagnoses, prior conservative treatment requirements, and treatment frequency. When searching CMS policies, verify the effective dates of the document to ensure the most current information.

  • MAC carrier, Novitas (AK, CO, DE, DC, LA, MD, MS, NJ, NM, OK, PA, TX) is accepting public comments through March 30, 2024, on their facet joint intervention policy.
  • Proposed LCD – Facet Joint Interventions for Pain Management (DL34892) (
  • Third party carriers have their own policies, which may differ between plans for these procedures as well. Requirements may include physical therapy, NSAIDs, etc. prior to an invasive procedure.


  • Verify insurance carrier policies on a regular basis.
  • Following individual carrier policies helps decrease unnecessary denials.



  1. Payers make money by denying claims, which slows down and possibly reduces payments.
  2. Your documentation is the key ingredient to preventing, and successfully appealing, denied claims.
  3. The provider’s documentation must clearly state what was performed and why.
  4. Coders and billers are grateful when documentation is clear, specific, and concise on a consistent basis.
  5. Claim denials will drop and your payments will increase.


References: AMA/CPT, CMS

StreamlineMD provides Revenue Cycle Solutions to Radiology & Interventional Specialists. Our Mission is to Improve Healthcare for All Americans.  Our Core Values that guide us on our mission are Service Quality, Teamwork, Accountability, Efficiency, Adaptability, Communication, and Integrity. Learn more about us at


Share the Post:

Related Posts