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Question: When may an anesthesia provider report separately a peripheral nerve block performed during the same encounter as another anesthesia service?

Arkansas Subscriber

Answer: Reporting a block separately depends upon the block’s primary purpose.

A peripheral nerve block used as the surgical anesthetic is part of the anesthesia service and is not separately reportable. On the other hand, separate reporting may be supportable when the block is performed primarily for postoperative analgesia and the surgical anesthesia does not depend on the block’s effectiveness. The American Society of Anesthesiologists (ASA) explains in its Statement on Reporting Postoperative Pain Procedures in Conjunction with Anesthesia that you may report a postoperative pain procedure with an anesthesia service when a different technique, such as general or neuraxial anesthesia, serves as the primary anesthetic.

To report a peripheral nerve block separately, make sure documentation establishes that the block was performed for postoperative pain management, identifies the block as a distinct procedure, and shows that general anesthesia or another anesthetic technique remained the primary anesthetic. The separate procedure note should capture the block’s purpose and the relevant procedural details rather than leaving the reviewer to infer them from the anesthesia record. For more information regarding anesthesia documentation, look to ASA’s Statement on Documentation of Anesthesia Care, which calls for accurate and thorough documentation throughout the perioperative period according to applicable regulatory, legal, and compliance requirements.

When reporting a postoperative pain block separately, ensure that you calculate anesthesia time in accordance with CPT^® and payer-specific reporting requirements.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC