Anesthesia Coding Alert

Brachial plexus block sounds like a wrestling move, and many coders wrestle with whether to include the post-operative continuous catheter with their anesthesiologists global period billing in order to receive proper reimbursement.

If you assume that every post-operative brachial plexus continuous catheter placement your anesthesiologist performs is bundled into the surgical procedure, you could be costing your practice around $82 per patient. Knowing when you can -- and can't -- report 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) is as easy as following three expert tips.

After shoulder surgery, patients often need pain management. When the surgeon asks your anesthesiologist to provide a brachial plexus catheter, you may be tempted to skip reporting 64416 assuming the post-operative pain service is included in the surgical coding.

Often, however, you can justifiably report 64416 and seek payment. When your anesthesiologist places a continuous catheter to administer the brachial plexus block, you should separately report 64416.

Here's why: The Correct Coding Initiative's (CCI's) guidance on routine postoperative pain management services indicate that it is included in the global surgical fee and "shall not be reported by the anesthesiologist unless separate, medically necessary services are required that cannot be rendered by the surgeon." An axillary block, which a surgeon does not have the expertise or training to do, would be a separate reimbursable service.

"Any kind of shoulder repair surgery -- rotator cuff, partial rotator cuff, total replacement -- is one of the more common uses of nerve blocks for post operative pain," says Joanne Mehmert, CPC, CCS-P, owner of Joanne Mehmert & Associates in Kansas City.

Example: An orthopedic surgeon performs a total shoulder replacement. Before the operation, the surgeon requests in writing that your anesthesiologist do a brachial plexus block via a continuous catheter (64416) for post operative pain management. Your anesthesiologist places the catheter and the patient receives a general anesthetic for the repair of the shoulder. The catheter remains in place to allow the patient to wake up pain free. You can report 64416 appropriately independent of the surgical procedure in this case.

Beware: A payer would likely reject codes for starting patient-controlled anesthesia (PCA), however, since that service could be rendered by the surgeon. For example, you would not be able to separately report postoperative pain management services using 62318 (Injection, including catheter placement, continuous infusion or intermittent bolus, 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; cervical or thoracic) or 62319 (... lumbar, sacral [caudal]), depending on the catheter placement.

For many payers, you must append modifier 59 (Distinct procedural service) to 64416 unless specific payer policy disallows use of the 59 modifier with a single line item claim.

Reason: This informs the insurance payer that "the anesthesiologist did not use the injection or block as the means for anesthesia but was a separate procedure," says Tacy Brown, director of billing and compliance with Mountain West Anesthesia in Salt Lake City, Utah.

Money matters: If you skip reporting 64416 altogether, you could be costing your practice $82 per injection (2.27 relative value units based on the 2010 Medicare Physician's fee schedule times the $36.0846 conversion factor).

Don't miss: CMS dropped the 10-day global period for 64416 last year. That means that if your anesthesiologist did a follow up you can charge an E/M service such as 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient...) for maintaining the catheter.

You can only report 64416 separately if you have documentation from the anesthesiologist supporting the separate nature of the catheter. For instance, in the above example, the surgeon requested in writing that the anesthesiologist provide the continuous catheter. That indicates that the catheter procedure was separate from the surgical procedure.

The documentation in the patient's medical record should include the procedure performed, the catheter site, substance injected, and the dosage of the substance as well as the time of placement of the catheter or block injection.

Pointer: "One way to accomplish this is to have an area on the anesthesia record for documenting these items, such as separate boxes for the digital start and stop times of the injection or block," Brown says. Some payersmay require this information to prove that the minutes were not included in the anesthesia time.