Wiki Transversus abdominis plane (TAP) block for Postop Pain

[shorty11476]

Patient had Exploratory Laparotomy, Sigmoid Colectomy with Takedown of Enterovesicular Fistula and Colostomy. Anesthesiologist performed a TAP block for post operative pain. Which CPT code would I use 64486 (unilateral) or 64488 (bilateral)? Anesthesiologist did not specify LT or RT. Medical record does not specify where the block was placed either. Medicare is requiring a modifier to pay the claim.

 

[lcole7465]

Patient had Exploratory Laparotomy, Sigmoid Colectomy with Takedown of Enterovesicular Fistula and Colostomy. Anesthesiologist performed a TAP block for post operative pain. Which CPT code would I use 64486 (unilateral) or 64488 (bilateral)? Anesthesiologist did not specify LT or RT. Medical record does not specify where the block was placed either. Medicare is requiring a modifier to pay the claim.

The block sheet should have the information completed whether it a unilateral or bilateral block. This information would be need to have been provided before coding the nerve block in order to use the correct code. If the information is not in the documentation, you would have to querry the provider and they will have to provide an addendum to the documentation with this information to support it. You would only need the modifier with 64486, if the block was placed on one side or the other, no modifier is required with 64488 as bilateral is stated in the description.

 

[mcnaryk]

I agree, you need to ask the provider if this was unilateral or bilateral to correctly assign the CPT. The only modifier I would add is a 59 since you mention it was for post op pain.