Revenue Cycle Insider

Hint: In some situations, you need to know whether the surgeon requested a block.

Postoperative pain blocks are used to manage acute pain following a surgical procedure. They are billed in addition to the primary anesthesia code. For these blocks to be billable, there must be documentation that the block was requested by the surgeon and was performed specifically for postoperative pain management.

Check in on this coding guidance and then test your knowledge with two coding scenarios.

Learn to Code These 2 Blocks for Postoperative Pain

Peripheral nerve blocks can be reported along with the anesthesia code when the mode of intraoperative anesthesia is general, subarachnoid injection, or epidural. Ultrasound guidance is currently included in most nerve block CPT^® codes, but as codes are updated each year and new codes are added, it is important to note any codes that can also be billed with code 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) if ultrasound guidance is used. Always verify the current year’s CPT^® guidance regarding billing of ultrasound with nerve block codes.

Epidural nerve blocks may be billed for postoperative pain only if the mode of intraoperative anesthesia is general. If the mode of intraoperative anesthesia is dependent on the epidural injection, then it is not separately billable. For example, code 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) may be reportable for each day after insertion for management of the epidural, but it is not reportable on the date of insertion.

HCPCS and CPT^® modifiers to consider:

• For laterality, report RT (Right side (used to identify procedures performed on the right side of the body)), LT (Left side (used to identify procedures performed on the left side of the body)), or 50 (Bilateral Procedure), if applicable
• For a separate service, report 59 (Distinct Procedural Service) or XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service)

Always check payer policies to determine whether the payer has specific guidelines regarding peripheral or epidural nerve blocks billed in conjunction with an anesthesia procedure.

Follow the Rules on Epidural Nerve Blocks for Chronic Pain

Epidural nerve blocks for chronic pain have more stringent billing guidelines, per the Centers for Medicare & Medicaid Services (CMS). The patient should have a pain duration of at least four weeks. Documentation should be present indicating that the patient did not respond to less invasive care or has an inability to tolerate less invasive care. The pain must be severe enough to impact quality of life or function. And a history, physical exam, and radiological image must show radiculopathy, severe degenerative disc disease, post-laminectomy syndrome, or acute herpes zoster associated pain.

Always refer to payer policies and Medicare local coverage determinations (LCDs) to determine limitations such as number of sessions in a 12-month period, covered diagnoses, or number of nerve root levels or spinal regions that are medically necessary.

Do This When Coding for Chronic Pain

Below is a list of most common codes used in billing and coding for chronic pain injections. Please note that this is not meant to be all inclusive, and codes are subject to change yearly.

• Interlaminar epidurals: 62320 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance) to 62322 (… lumbar or sacral (caudal); without imaging guidance)

• Transforaminal epidurals: 64479 (Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level) to +64484 (Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure))

• Facet/medial branch blocks: 64490 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level) to +64495 (… lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure))

• Joint injections (small, intermediate, major): 20600 (Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance) to 20611 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting)

• Trigger point injections: 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) to 20553 (Injection(s); single or multiple trigger point(s), 3 or more muscles)

• Sympathetic nerve injections: 64505 (Injection, anesthetic agent; sphenopalatine ganglion) to 64530 (Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring)

Again, always consult Medicare LCDs and payer policies to determine coverage and correct coding for procedures covered in the above categories.

Important: Medicare considers moderate or deep sedation, general anesthesia, or monitored anesthesia care not medically reasonable or necessary when performed during a nerve block. Only in exceptional and unique cases will it be considered and documentation must be present to establish the need for sedation. A needle phobia or anxiety does not qualify as an exception.

Try These Examples to Check Your Coding

Example 1: The patient has a laparoscopic hysterectomy under general anesthesia. The anesthesiologist also performs a bilateral transversus abdominis plane (TAP) block with ultrasound guidance at the surgeon’s request to help control postoperative pain. What procedures codes does the anesthesia group bill?

• For anesthesia: Report 00840 (Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified) plus any medical direction modifiers that are appropriate.
• For the postoperative block: Report 64488-XU. Do not report 76942 due to the ultrasound being included in the description for 64488 (Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed)).

Example 2: The patient presents with chronic low back pain radiating down the left leg, consistent with lumbar radiculopathy. Symptoms have persisted for over eight weeks despite conservative therapies. The pain limits the patient’s daily activities. A lumbar transforaminal epidural steroid injection is performed at L4-L5. Fluoroscopic guidance is used for needle placement. What procedure code should you report?

• For epidural injection: Report 64483 (Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level). Do not report +77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)) due to the fluoroscopy being included in the descriptor for 64483.

Remember: Proper documentation, adherence to payer policies, and accurate coding are essential for successful billing of nerve blocks, whether used for postoperative pain or chronic pain. Staying up to date on all payer policies helps ensure accurate coding, compliance, and proper reimbursement.

Julie McDaniel, MHA, CPC, CANPC, Vice President,
Rock Medical Practice Solutions