Take the Hurt Out of Post-op Pain Block Coding
By Jennifer Hritsco-Murray, CPC, CANPC
Under Medicare guidelines, pain management following surgery usually is included in the surgeon’s global fee and may not be billed separately. If another physician (such as an anesthesiologist) provides pain management at the surgeon’s request, however, it’s possible to report the service independently.
Specifically, according to the American Society of Anesthesiology (ASA), CPT® recommendations, Correct Coding Initiative (CCI) edits, and the Centers for Medicare & Medicaid Services (CMS) guidelines, when medically necessary a block performed for post operative pain only (which is not a part of the anesthesia service) may be billed separately with the proper modifier. The surgeon is responsible for documenting in the patient’s medical records why post-op care was given to the anesthesiologist.
Account for Time Appropriately
You must pay attention to block placement timing, and be sure that your anesthesiologist is not billing time plus the flat rate fee inappropriately.
Do not deduct time for the block when:
- The block was done in the holding area before anesthesia time had started. Depending on the patient and the anesthesiologist, the block may be done in the holding area before the patient is taken into the operating room (a block may be done prior to the surgical procedure even though the block is for post-op pain). Anesthesiologist time starts when the patient is preparing in the operating room (OR) for surgery. Your anesthesiologist should not start his time when the patient is in the holding area, so there is no need to subtract time for the block.
- The block is part of the anesthetic itself. For instance, if the anesthesiologist places a nerve block but the patient had intravenous (IV) sedation only, the block is considered part of a regional anesthetic and should not be billed separately. As an example, if a spinal block (such as 62311 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)) is performed with IV sedation for a hip surgery, consider the block part of the regional anesthetic. Report the appropriate anesthesia code and time, but do not report 62311.
- The patient is fully under anesthesia when the block is performed. These cases are rare, but may occur. For instance, if the patient is unable to hold still to receive the block (for example, due to patient age or mental status).
You should deduct time for the block from the total surgical procedure’s anesthetic time when:
- The patient is in the operating room, the anesthesiologist has started his time, and the patient is not under induction (ASA House of Delegates, Oct. 17, 2007 updated Sept. 2, 2008). In most cases the anesthesiologist would place the block prior to induction, for clinical and safety reasons.
For example, prior to placing the patient under general anesthesia, a block (for instance, 64415 Injection, anesthetic agent; brachial plexus, single) is given in the OR for post-op pain. The total time from when the patient was prepared, started, and finished equals 67 minutes, the anesthesiologist started his time when the patient was prepared for surgery in the OR. The anesthesiologist noted in his record that he placed the block after monitors were placed. Because the block was done prior to induction, don’t count the time it took to place the block. It took him seven minutes to place the injection prior to induction so subtract the seven minutes from the 67 minutes, billing a total time of 60 minutes. In this case, the block may be billed (64415-59 Distinct procedural service) in addition to the general anesthesia code plus time (for instance, 01630 Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not otherwise specified.
Remember: Add modifier 59 to any block codes not related to the anesthesia for the procedure.
Report What Documentation Supports
The physician should document the nerve he or she is targeting for post-op pain. Most often the documentation is there, and with a proper understanding of the nerve anatomy there is no problem verifying the correct code to use.
If documentation is unclear, do not make assumptions. Instead, ask the reporting physician for guidance. You can get the best results by asking physicians for clarification, and then helping those physicians understand what documentation is necessary to support the procedures or services performed. The better physicians understand documentation requirements, the more consistent and accurate your coding will be.
Consider this example: The physician documents popliteal fossa block for post-op pain of the lower extremity. The popiteal fossa is not a nerve—it is a triangular space just above the back of the knee where the nerve injection was approached. This triangle is where the sciatic nerve splits into the tibial and common peroneal nerve (the tibial and common peroneal nerves are branches of the sciatic nerves). In most cases, the popliteal nerve block is an approach for the injection of the sciatic nerve by the means of a prone positioned patient; however, the same area also can block the tibial or the common peroneal nerve.
Questions: Was the focus of the post-op block the sciatic, tibial, or common peroneal nerve? Is the appropriate code 64445 Injection, anesthetic agent; sciatic nerve, single or 64450 Injection, anesthetic agent; other peripheral nerve or branch (there are no specific codes for the tibial or the common peroneal nerve listed in the CPT®)? If the physician documents precisely, it is not a hard question; however, in this case it’s hard to determine because the documentation seemingly lacks enough information to support 64445. If the documentation lacks the support to code accurately, you must report 64450.
Hint: You may find documentation to support 64445 on the permanent record of the real-time ultrasonic/ultrasound picture. The physician should’ve labeled the nerves and needle placement in the real-time image where the local anesthetic pool is located.
Guidance May Be Separate With Injection
CCI edits allow you to bill separately for ultrasonic guidance using 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation with modifier 26 Professional component, as long as your physician has permanent recording and reporting in the patient medical records. Ask your physician to provide a photocopy of this document. Attach it to the billing before you allow it to be coded and charged out. Look out for CCI edits going forward to be sure future edits do not change the rules for reporting guidance with injection.
Being a coder is like being a detective. You must look at all the “evidence”—including the ultrasonic guidance picture—and ask yourself what type of surgery this is, what the block is being used for, and whether the block was part of the anesthesia or provided by the anesthesiologist to control post-op pain. Call on all available resources (for instance, CCI edits, CPT® Assistant, and your local Medicare carrier local coverage determination (LCD)/national coverage determination (NCD)) to ensure your coding is valid. If you are unsure of anything, ask your physician for guidance and look again at the documentation. If the documentation doesn’t support the code the physician wants to report, tell him or her why. Make sure you have support for your reasoning, and attach the information to the charge (or keep it in a folder). Such supporting documentation is especially important if you have to appeal a claim.
Jennifer Hritsco-Murray, CPC, CANPC, has worked in health care for 13 years, beginning as a Certified Nurse Assistant (CNA). She has been employed with Missoula Anesthesiology, PC for 10 years, and codes procedures for the Advanced Pain & Spine Institute of Montana since 2005. She is president-elect of the Missoula Chapter, where she previously served as new member development officer.