Eli's Rehab Report

When used correctly, the four somatic nerve block codes (64416, 64446-64448) that CPT 2003 introduced will help pain management providers better code services for patients who require immediate postoperative physical and occupational therapy.

PM&R practices will probably benefit most from the new single femoral nerve block code (64447, Injection, anesthetic agent; femoral nerve, single) because outpatient practices can administer single blocks more easily than they can provide a continuous infusion, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

"In the outpatient setting, I could foresee 64447 being used as a diagnostic tool to evaluate possible femoral nerve injuries," Hammer says.

Because the single femoral nerve block only lasts for about six hours, it won't benefit patients who require round-the-clock pain management, Hammer says.

On the other hand, "Pain management providers might offer this type of injection to a patient who had knee adhesions, and the pain prevents them from tolerating physical therapy postoperatively. The nerve block would allow the therapist to more effectively treat the patient and produce greater results," she suggests.

Although CPT changed the nerve block code, the billing rules probably remain the same, says Joni Atanaski, office manager at Gate Rehab, a two-physician, one-therapist practice in Parsippany, N.J.

"In the past, when the physiatrist gave the patient a femoral nerve block and then the therapist did therapeutic exercises, we billed 64450* (Injection, anesthetic agent; other peripheral nerve or branch) along with 97110 (Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility)," Atanaski says. "I called our carrier to see how the new code would affect how to bill this type of situation, and they told me it would probably actually be easier now, since we no longer have to send the documentation to support use of the unlisted code."

Although the Correct Coding Initiative (CCI) has not released any information about how the new codes will be bundled with other CPT codes, Atanaski says she doesn't expect to see any edits barring her from billing the femoral nerve block code with physical therapy because these two services traditionally go hand-in-hand. Therefore, practices should be able to bill a physician's evaluation, the femoral nerve block code and therapy services on the same day.

Physiatrists will probably use the new continuous infusion codes (64416, 64446 and 64448) postoperatively for pain management. The AMA's CPT Changes 2003: An Insider's View suggests that you might use 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) to report pain relief and vasodilation following traumatic amputation of a patient's thumb and forefinger.

"The surgeon often requests continuous catheter pain management not only to control pain but to allow for earlier postoperative therapy to the affected sites," Hammer says.

Likewise, physiatrists might use 64446 (Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter [including catheter placement], including daily management for anesthetic agent administration) to describe postoperative pain control following major foot and ankle reconstruction. CPT Changes 2003 suggests that the sciatic block might also allow earlier ambulation.

"The clinical example offered at the AMA CPT 2003 conference for 64448 (Injection, anesthetic agent; femoral nerve, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) referred to postoperative pain control and increased knee mobility following a total knee replacement (27447)," Hammer says.

The new continuous infusion codes carry a 10-day global period, so only report E/M services during this period if you evaluate a condition unrelated to the pain management infusion.

For example, the physiatrist administers a continuous sciatic block (64446) following a patient's foot surgery. Six days later, the patient presents to the PM&R practice, and the physiatrist evaluates her arthritis flare-up. Report the E/M service with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended, along with documentation showing that the physiatrist treated the patient's arthritis and not her foot injury during the E/M visit.

Editor's note: Consultant Marvel Hammer can be reached by e-mail at marvelh@aol.com.