Managing Postoperative Pain Is a Joint Effort

Coding and documentation should reflect new changes to both surgical and anesthesia reporting.

By Kelly D. Dennis, MBA, CPC, CPC-I, CANPC, ACS-AN, CHCA 
Postoperative pain management (POPM) is a team effort between the surgeon and the anesthesia provider. Changes in coverage affect both surgeons and anesthesia providers, and coders from various specialties should pay attention to new guidance regarding coding and documentation for POPM.
Conditions Apply for Separate
Payment of Post-op Pain
There were verbiage changes in the National Correct Coding Initiative’s (NCCI), Anesthesia Services section, chapter II, pages II-7 through II-12, version 18.0 (effective Jan. 1, 2012) and chapter II, pages II-6 through II-15, version 19.0 (effective Jan. 1, 2013). These changes outline the circumstances under which acute pain management is payable, and emphasize the requirement of documentation from the surgeon requesting assistance from an anesthesia provider.
A recent proposed draft local coverage determination (LCD) by Noridian Administrative Services, LLC, “Nerve Blockade: Somatic, Selective Nerve Root, and Epidural” (DL33188), regarding POPM indicates, “Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control.” As written, the Noridian LCD would drastically change the way anesthesia providers are paid for anesthesia services.
Both the American Society of Anesthesiologists (ASA) and anesthesiologists who serve on their state carrier advisory committee (CAC) are working to ensure Noridian has a clear understanding of acute pain management services. Initial responses to comments from contractor medical directors at Noridian during recent CAC meetings suggest there will be significant changes in the current LCD draft’s language; however, coders and anesthesia practices from any state had until July 11, 2013 to submit comments regarding the LCD draft.
The NCCI verbiage changes and the proposed LCD draft are based on the Centers for Medicare & Medicaid Services (CMS) Medicare Claim Processing Manual, chapter 12 – “Physicians/Nonphysician Practitioners” premise that postsurgical pain management by the surgeon is included in the global surgical package. The NCCI , however, recognizes the ability of the surgeon to “request the assistance of the anesthesia practitioner if the degree of postoperative pain is expected to exceed the skills and experience of the operating physician to manage it.” NCCI also indicates POPM procedures may be “administered preoperatively, intraoperatively, or postoperatively.”
Although post-op pain is the responsibility of the surgeon and payment is bundled into the surgeon’s global fee, anesthesia services may be reported separately if:

• The services are requested by the surgeon for an anesthesia practitioner to provide POPM; and
• Anesthesia for the surgical procedure is not dependent on the efficacy of the regional anesthetic technique.

The ASA Relative Value Guide® (RVG®™), 2013 Reporting Postoperative Pain Procedures in Conjunction with Anesthesia (pages 58-65) indicates the following conditions apply:

1. Anesthesia for the surgical procedure was not dependent on the efficacy of the regional anesthetic technique;
2. Time spent on pre- or post-op placement of the block is separated and not included in reported anesthetic time; and
3. Time for a post surgical block that occurs after induction and prior to emergence does not need to be deducted from reported anesthesia time.

The RVG®™ also suggests documenting the surgeon’s request; however, according to the NCCI, the “surgeon is responsible to document in the medical record the reason care is being referred to the anesthesia practitioner.” This provision requires a written request from the surgeon, which indicates there must be communication between anesthesia and surgical staff to ensure the requirements for POPM are well documented for each patient on a case-by-case basis.
Code Post-op Pain Procedures
Procedure coding will depend on the site of the injection area and placement of either a block(s) or a continuous catheter. See Table 1 for some of the more common CPT® codes associated with POPM services.
Table 1: Common CPT^® codes associated with POPM services

The appropriate CPT® code(s) should be appended with modifier 59 Distinct procedural service to signify the service or services were distinct from the anesthesia provided for the surgery.
Remember: If the block/catheter was used for the surgery, the procedure is not separately billable; however, discontinuous anesthesia time may be reported for the time spent placing the block/catheter.
For example: If a carpal tunnel procedure is being performed with a wrist block, a code from the CPT® anesthesia section (01810 Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand plus the anesthesia time for both the anesthesia during the wrist surgery and for placing the wrist block) is reported. A separate code is not reported for the wrist block.
Always check the documentation carefully and ensure you understand the procedure being performed.
For example: Several terms are used to describe a “brachial plexus” block, such as “interscalene,” “infraclavicular,” or “supraclavicular.” Do not confuse these with codes with a similar sounding description (such as “suprascapular”).
A “popliteal” block procedure note, without a description of the anatomy, is not helpful in determining the correct code to report. A “popliteal fossa” injection is reported with 64445 (sciatic nerve); whereas a “saphenous popliteal” is reported with 64450 (other peripheral nerve block).
Also, transversus abdominis plane (TAP) blocks do not have a specific procedure code. CPT® code 64450 may be used; however, CPT® code 64425 may be appropriate for TAP blocks performed for inguinal hernia repair when the ilioinguinal/iliohypogastric nerves are anesthetized (Mariano, “Billing for Regional Anesthesia).” If you are unclear about the services provided, confirm all questionable details.
If ultrasound guidance is used and appropriately documented, CPT® 76942 Ultrasound guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation may be reported separately (with modifier 26 Professional component, if applicable). Documentation of ultrasound alone is not sufficient. According to CPT® non-obstetrical ultrasound coding guidelines, “Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.” A retrievable image should be available, along with a procedure note describing the ultrasound use for block placement.
When reporting anesthesia, remember that codes obtained from the surgery and radiology section are flat-fee. Although no time is reported separately, documentation must support the time the block was placed (i.e., 7:21 p.m. to 7:34 p.m.) to clearly distinguish it was separate from the reported anesthesia time, when applicable.
Daily Pain Management
Reporting daily management of post-op pain will vary, depending on the services provided. According to the NCCI, “CPT code 01996 may only be reported for management for days subsequent to the date of insertion of the epidural or subarachnoid catheter.” CPT® 01996 Daily hospital management of epidural or subarachnoid continuous drug administration would not be reported for other types of continuous catheters, such as 64416, 64446, and 64448.
Determine whether the documentation supports an evaluation and management (E/M) service, including the chief complaint (related to post-op pain) and at least two of the three required elements for subsequent hospital care (history, examination, and medical decision-making (MDM)). Keep in mind that if the surgeon has transferred responsibility for POPM to an anesthesia provider, only one physician or qualified healthcare professional should report these services.
For example: If a continuous interscalene catheter is used for POPM, and the catheter is left in place, documentation for the follow-up days should include:
Chief complaint – You should not be expected to presume POPM.
At least two of the following three components:
a.) History (i.e., location, quality, severity, duration, time, etc.)
b.) Examination (The extent of the examination performed is dependent upon the examiner’s clinical judgment, the patient’s history, and the nature of the presenting problem.) The documentation should reflect whether the catheter site was examined and all pertinent information.
c.) MDM (Is the patient stable, improving, progressing as expected or resolved? Have any problems been addressed? Is the pain being properly managed?)
Because the surgeon has transferred the post-op care to an anesthesiologist, the surgeon should not report these services in addition to the anesthesia provider. Remember also to check with the payer, as policy may limit the number of reportable or covered follow-up days.
ICD-9-CM Coding
Acute pain diagnosis codes are separately identified in section 338 of ICD-9-CM—although, there is confusion regarding reporting a diagnosis code from this section.
According to ICD-9-CM guidelines, “Routine or expected postoperative pain immediately after surgery should not be coded.” The guidelines also state, however, “If pain control/management is the reason for the encounter, a code from category 338 should be assigned as the principal or first-listed diagnosis” and “may be reported as the principal or first-listed diagnosis when the stated reason for the admission/encounter is documented as postoperative pain control/management.”
Because routine pain management is provided by the surgeon, it’s my opinion that a category 338 code should be reported when anesthesia is requested to provide POPM. In the aforementioned Noridian draft policy, however, these diagnosis codes are listed as Group 1 and identified with an asterisk (*) to indicate, “Reimbursement for the control or management of pain in the immediate postoperative period is bundled into the payment for the procedure, surgical or anesthetic-regardless of the method by which the care provider, including the anesthesiologist, decides to manage the pain” (see Table 2). Again, please note those involved in the CAC process believe the Noridian draft policy is likely to be revised substantially.
 
Table 2: Group 1 medical necessity ICD-9-CM code

 
Historically, anesthesia practices have relied on documentation by the anesthesia provider to support the surgeon’s request for POPM, such as a procedure note or anesthesia record indicating the surgeon’s request. In the current environment, you should rely on the documentation guidelines as outlined in the NCCI and the recommendations listed by the ASA. Documentation in the medical record must support the surgeon’s transfer of care. This requirement means anesthesia practitioners should request written, rather than verbal, communication.

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