Anesthesia Coding Alert

Hint: Look to the anatomical approach to find the right code.

Procedure coding will depend on the site of the injection area and placement of either block(s) or a continuous catheter. Coders should check the documentation carefully and ensure they understand when postoperative pain management (POPM) is separately reportable and understand the procedure being performed. For example, several terms are used to describe a “brachial plexus” block — such as “interscalene,” “infraclavicular,” or “supraclavicular.” These descriptions are approaches to the brachial plexus and not the targeted nerves.

Coders May Need to Rely On Queries to Ascertain Details

A “popliteal” block procedure note, without a description of the anatomy, is not helpful to coders in determining the correct code to report. If coders are unclear about the services provided, such as whether popliteal is referring to a sciatic or ankle block, they should confirm all questionable procedure details to assign a correct code. See the table below for some of the more common CPT^® codes associated with POPM services, including the new fascial plane blocks and catheters:

However, although new fascial plane blocks provided listed codes for many of the previously unlisted procedures, there may still be times when an unlisted code will apply, such as a cervical plexus block or lumbar erector spinae (ESP) block. Use caution when utilizing online resources, as there is more than one type of ESP block. A single ESP block into the thoracic fascial plane is reported as 64466. Coders should also note ultrasound guidance is now bundled into most of these block codes.

See When Modifiers Apply

The appropriate CPT^® code(s) should be appended with either modifier 59 (Distinct procedural service), XE (Separate encounter), or XU (Unusual non-overlapping service) to signify the service or services were separate and distinct from the anesthesia provided for the surgery. Payers may have various modifier requirements, so check payer policy.

Since 2024, the Centers for Medicare & Medicaid Services (CMS) has required an XU modifier rather than a 59 modifier, although they have continued to pay a 59 modifier when reported. According to both the National Correct Coding Initiative (NCCI) and Medicare Learning Network bulletin MLN1783722 for proper use of modifiers, “when another already established modifier is appropriate it should be used rather than modifier 59.”

Report Use of Ultrasound Guidance, Too

If ultrasound guidance (USG) is utilized and appropriately documented and the code description does not indicate “including imaging guidance, when performed,” report 76942 (Ultrasound guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation) separately with modifier 26 (Professional component) (for example, 64450 or 64999).

Note: Documentation of the use 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 use of ultrasound for placement of the block.

Payers may deny USG unless the documentation supports the validity and accuracy of the billed service and payers are looking for procedure note documentation to support ultrasound evaluation of potential access sites; documentation of selected vessel patency; concurrent real-time ultrasound visualization of vascular needle entry; and permanent recording and reporting that closely resembles the code description. If your anesthesia group has a template for USG services, make sure they include these elements. It is also important for anesthesia coders to remember that codes obtained from the surgery and radiology section are flat-fee and no time is reported separately.

Pay Attention to Language in Post-Op Notes

Reporting daily management of postoperative 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.”

Pay attention to the wording concerning continuous catheters, as the epidural and subarachnoid catheter code options are with and without imaging guidance. Codes 62323 and 62325 cannot be reported in conjunction with 76942. You can report 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) for the codes ranging from 62323 to 62325; you cannot report 01996 for other types of continuous catheters, such as CPT^® codes 64416, 64446, 64448, 64467, 64469, or 64474.

Since 01996 is not an option for these procedures, coders must determine whether the documentation supports an evaluation and management (E/M) service, including the chief complaint (related to postoperative pain). Keep in mind that if the surgeon has transferred responsibility for postoperative pain management to an anesthesia provider, only one physician or qualified healthcare professional (QHP) should report these services.

Don’t Forget to Incorporate Diagnosis Codes

Acute pain diagnosis codes are separately identified in the ICD-10-CM Chapter 6 guidance. However, there is some confusion regarding reporting a diagnosis code from this section. According to the chapter-specific coding guidelines, “Routine or expected postoperative pain immediately after surgery should not be coded.” The guidelines also state that “If the encounter is for pain control or pain management, assign the code from category G89 followed by the code identifying the specific site of pain.” As routine pain management is provided by the surgeon, you could report a category G89.11 (Acute pain due to trauma) to G89.18 (Other acute postprocedural pain) code when anesthesia is requested to provide POPM.

Diagnosis codes in the table below are included in the covered codes from billing articles by Medicare Administrative Contractors (MACs) FCSO, NGS, and Palmetto local coverage determinations (LCDs). So, whether coders choose to report Category G, anatomical pain location, or both does not generally affect payment of the claim — as long as a pain diagnosis is listed in the POPM procedure note and the documentation requirements are met. Watch your denials closely for payer-specific requirements.

Anesthesia practices rely on documentation by the anesthesia provider to support the surgeon’s request for POPM, such as a procedure note or anesthesia record indication of the surgeon’s request. For many years, coders have relied on the documentation guidelines as outlined in the NCCI and American Society of Anesthesiologists (ASA) recommendations, yet allowed documentation showing “block requested by surgeon” or something similar to suffice. In the current environment, documentation in the medical record must support the surgeon’s transfer of care to anesthesia. This requirement means that anesthesia practitioners should request written, rather than verbal, communication. When a payer requires proof of a surgeon’s order, you will need this documentation to either get paid or keep the money that was already paid.

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPMA,
CPC, CPC-I, Perfect Office Solutions