Help! Pain pump

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Pensacola, FL
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Are any of you in the ASC setting billing for a pain pump? I'm having a hard time finding the correct code to bill. Here is an example of an op note that I sent to a separate coding company to help me. They coded with a 49999 for the abdominal exploration and A4300 for the On'Q pain catheter. My questions are, would there not also need to be a code for the resection of the nerve branches? And is the A4300 the correct code for the On-Q and pump?

DESCRIPTION OF PROCEDURE: Mr. X has had several blocks, currently improved his pain in his left upper abdominal wall. He was able to localize his pain to a region approximately size of a quarter. We discussed specifically in great detail of the risk and benefit of the surgery and he was well aware of these risks due to his previous operations, but those risks include and were not limited to bleeding, infection, damage to nerves and vessels, need for further surgery, incomplete resolution of symptoms, and worsening of symptoms. He signed the consent form. He was taken to the operating room and placed in a supine position. We had marked the location of his pain preoperatively and this correlated with his preoperative blocks, all of which were at least modestly successful with at least a four-point drop in his pain, if not five. The surgical site was then marked and I used a 15-blade scalpel and a transverse incision to connect the two previous incisions that he had one medial and one lateral. I carefully divided the subcutaneous tissue down to abdominal wall fascia. Careful retraction was used and I searched the external oblique fascia for any evidence of the T8 or T9 intercostal nerve root, lateral branch that reached out and was likely in this portion of his abdominal wall. I searched the region measuring approximately 10-cm x 20-cm in width. This was well outside the borders of the quarter sized area where he reported his pain to be. I did not identify any substantial peripheral nerves, but I did identify one small structure of more than a tiny nerve branch. This was cauterized and resected. I sent the specimens to pathologist. I then continued my search in the same plane, but still could not find any. I then carefully searched the similar subcutaneous tissue. I felt that if this was consistent with diagnoses that we had previously documented, but the location of this branch should have been identified this time. I do not identify any branches in the subcutaneous tissue. The patient was morbidly obese and the subcutaneous tissue was quite thick. The decision was made to stop searching and to implant an “On-Q” pain catheter. We therefore filled up 400 cc of 0.25% Marcaine from the On-Q pump balloon up. I then secured this to a 5-mm per hour catheter. It was placed through a separate large irrigation needle into the subcutaneous pocket on the level of the abdominal fascia. I then flushed the catheter.

I irrigated the abdominal wall with saline and then closed in layers with 3-0 Monocryl deep and Scarpa's layers and then 4-0 Monocryl deep dermal and 4-0 Monocryl subcuticular and Dermabond. A sterile dressing was applied. The catheter itself was also put in place and placed under several Tegaderm. The patient was awoken from anesthesia and transferred to the recovery room in stable condition.

Thanks for any help!
 
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