When it comes to submitting peripheral nerve block claims that have any chance of being paid, the burden of proof is on you. You'll need to educate payors about your regional anesthesia program's clinical and financial benefits, and demonstrate a distinction between the intraoperative anesthesia regimen and the peripheral nerve block used to manage post-op pain. Follow these six steps to build a profitable nerve block program.

Step 1. Court your surgeons. Remember that surgeons make contact with patients during their pre-op visits several weeks to months before surgery. Given this long-term doctor-patient relationship, surgeons who support regional anesthesia can recommend nerve blocks to patients before the day of surgery, leading to higher utilization. Proactively address surgeons' concerns regarding regional anesthesia, such as failed blocks, complications and case delays (see "Dispelling 8 Peripheral Nerve Block Myths" at www.outpatientsurgery.net/2009/01).

Step 2. Show and tell. If you use a billing service, get to know the people who send out your charges. Meet them in person and explain what you do and why you do it. If feasible, have your billing manager observe nerve block procedures and patients' post-surgical recovery. By arming your billing staff with knowledge of your techniques and outcomes, they'll be better equipped to negotiate charges and fair reimbursement with each payor.

Step 3. Select a delivery model. The costs to implement a peripheral nerve block program vary according to the model you choose. You can build the most basic and low-cost PNB program on traditional paresthesia-seeking techniques, which involve sticking needles blindly around a target area until you locate the nerve. Tacking on technology to the base PNB delivery method will ratchet up the program's performance and cost.

For example, electrical nerve stimulators cost several hundred dollars and the insulated needles required for this technique run between $12 and $15 per case. Adding ultrasound guidance, meanwhile, will take a $30,000 to $70,000 chunk out of your capital equipment budget. Once you incur the initial capital expense of the ultrasound unit, however, the single-use sterile sleeves needed to cover its probe are relatively inexpensive. Using ultrasound guidance can potentially decrease marginal costs by replacing more expensive stimulating needles with cheaper traditional block needles. Facilities hosting a high volume of PNB cases might also need to consider adding an anesthesia provider, along with her six-figure salary and benefits package, to place blocks in a dedicated block room.

Step 4. Bundle costs. Over coffee one morning I asked our hospital's perioperative services director how he captured charges for our PNB supplies. The look on his face said it all: "How much are we talking about?" It was then that I realized that drilling down to how your facility bills for supplies is a valuable exercise, especially in a large hospital with many moving parts between the OR and billing office.

After tracing an anesthesia record along our billing chain of action, I realized our hospital's anesthesia equipment and pharmacy charges were not routinely itemized, so patients received flat charges in these two areas. PNB and continuous peripheral nerve block (CPNB) placement introduce additional equipment and medications not normally included in the typical general anesthetic protocol, including skin antiseptic, local anesthetic, needles and syringes. We developed separate charge bundles with itemized lists of supplies used for single-injection, CPNB and ultrasound to capture appropriate perioperative fees, minimize loss and collect additional revenue. The value of each bundle is based primarily on materials and medications used to deliver the block, and varies between facilities because of individual negotiations with supply vendors.

Step 5. Design separate documents. During the first 18 months of our PNB program, our anesthesia records didn't adequately distinguish between intraoperative techniques and PNB administration. To avoid potential double-billings, our internal billing service charged for the highest ticket item on each anesthesia report, whether that was the intraop anesthesia or the PNB, causing us to miss out on fees we were entitled to collect.

When you perform nerve blocks for post-op pain, they're considered separate from intraoperative anesthetic care. Develop and use a distinct anesthesia procedure note to record the details of the block administration. That standalone form will separate the block from the intraoperative anesthesia regimen in the eyes of the insurers. Having different providers perform the block and fill out the anesthesia procedure note will further separate the nerve block from the intraoperative anesthetic technique. If the nerve block is used for intraoperative anesthesia, don't use this separate form; otherwise, you'll appear to be double-billing.

Involve your clinical managers when designing new forms to ensure compliance with your facility's policies and mandates from regulatory agencies. Make them easy to read and use. Our customized regional anesthesia procedure note contains check boxes so providers can quickly note the type of block they provided, whether the block was single-injection or continuous, and the corresponding procedure codes. Submitting a separate PNB claim gives us a greater chance of being paid by insurers. The hospital's billing department uses the form to apply the correct charge bundle, which lets us capture charges for the additional supplies used for PNB cases more accurately than our previous system.

Step 6. Crack the codes. When billing for nerve block procedures performed for post-op pain management, include the modifier -59 to distinguish the block from the intraoperative anesthetic technique. This is especially important when the same provider performs the nerve block and the intraoperative anesthesia. Before January 2009, the CPT code for continuous nerve blocks included the 10-day follow-up period. At the beginning of this year, the Medicare fee schedule unbundled the follow-up for continuous nerve block catheters, and now we may be able to start claiming daily evaluation and management (E&M) using codes 99231 to 99233 for established in-hospital consults. We currently do not know if other insurance carriers will reimburse for E&M or how this change will affect payments for the procedures themselves.

When using real-time ultrasound guidance for nerve block procedures, use CPT code 76942. This code for ultrasound-guided needle placement comes from the radiology section of the CPT book. To charge appropriately for the use of ultrasound, your documentation must include an image taken during the procedure and an interpretation of findings (a limited interpretation, since this is not a diagnostic code). In our practice, we prefer to print an image and attach it to our procedure note with a text annotation identifying relevant anatomy, needle placement, injection of local anesthetic solution and avoidance of complications.

The modifier -26 limits the ultrasound charge to professional fee only. Without the professional fee modifier, CPT 76942 includes a technical component charge for equipment storage and maintenance. While we choose to include the -26 modifier when we bill for ultrasound-guided nerve blocks, this decision is facility-specific and should be determined by the anesthesia providers and facility managers charged with directing patient care.