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When it comes to getting paid for post-op pain blocks, not all payors require the same documentation and proof of medical necessity. Some commercial carriers follow the Medicare edits and guidelines while others don't follow Medicare reimbursement — potentially allowing for more aggressive coding and reporting. Here's a review of different post-op pain directives.
- American Medical Association. The AMA says it's appropriate to report pain management procedures for post-op analgesia separately from the administration of a general anesthetic. "Whether the block procedure (insertion of catheter; injection of narcotic or local anesthetic agent) occurs pre-operatively, post-operatively or during the procedure is immaterial," reads AMA CPT OCT 01; 9. The AMA lists 2 exceptions, however. One, if the block procedure is used primarily for the anesthesia itself, report the service using the anesthesia code alone. Two, don't report the block separately in a combined epidural/general anesthetic. Keep in mind that even though the AMA allows for separate reporting under specific circumstances, commercial carriers might have varying reporting and billing policies. Be sure to verify them.
- Centers for Medicare & Medicaid Services. CMS says there's no separate payment for post-op pain management when provided by the physician performing an operative procedure, noting on page 6 of the CMS Chapter 2 NCCI Manual that surgeons who provide post-op pain management are reimbursed under a global payment policy related to the procedure. CMS further states that anesthesia practitioners shall not report post-op pain procedures unless "separate, medically necessary services are required that cannot be rendered by the surgeon." In such cases, CMS says, "the surgeon is responsible to document in the medical record the reason care is being referred to the anesthesia practitioner."
Surgeons may report CPT codes 36000, 36410, 37202, 62318 to 62319, 64415 to 64417, 64450, 64470, 64475, and 90760 to 90775 "only if provided for purposes unrelated to the [post-op] pain management, the operative procedure or anesthesia for the procedure," according to Medicare Global Surgery Rules.
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Read LCDs in Their Entirety |
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It's easy to misinterpret local coverage determination policies for peripheral nerve blocks if you make it through the medically necessary conditions but omit the remaining contents of the LCD containing the documentation requirements. Take, for example, the following excerpt from First Coast Service Options' LCD:
"Medicare will consider peripheral nerve blocks medically reasonable and necessary for conditions such as the following diagnostic and therapeutic purposes: When a single injection peripheral nerve block provides post-surgical pain control 1. during the transition to oral analgesics 2. in those procedures that cause severe pain normally uncontrolled by oral analgesics 3. in cases otherwise requiring control with intravenous or parenteral narcotics. 4. in cases where the patient cannot tolerate treatment with narcotics due to allergy or side effects, etc." If you read only the excerpt above and not the LCD in its entirety, you'll miss the remainder of the LCD that reads: "Based on Medicare rules, regulations and Correct Coding Initiative (CCI) edits, nerve blocks are not separately payable when done by the surgeon or the anesthesia professional who provides anesthesia/analgesia for the procedure. When preemptive analgesia is performed by a provider other than the surgeon or the anesthesia professional who provides anesthesia/analgesia for the procedure, there must be a compelling patient care reason for the involvement of the additional provider. The rationale for this approach must be clearly documented in the medical record. Medical records must be available and submitted upon request." So even though you can prove medical necessity per the LCD for the performance of the post-op pain block, you must explain why an additional physician other than the surgeon or anesthesiologist in the case had to do the block. But beware. One LCD policy should in no way be interpreted and used as an overall coding policy. — Cristina Bentin, CCS-P, CPC-H, CMA |
Documenting blocks
While most pain management providers are usually on target when describing injection procedures, the ball gets dropped too often when it comes to documenting post-op pain blocks. Detailed documentation is essential and the post-op pain injection must be separate and distinct from the anesthesia used to perform the surgery. Many commercial carriers that allow separate reporting advise a separate operative report or procedure note for the injection. Likewise, many commercial carriers have medical necessity and provider requirements.
We found these examples of grossly deficient post-op pain block dictations within operative reports that provided no separate operative reports for the block:
- "The patient was given a block followed by endotracheal anesthesia."
- "Anesthesia: general endotracheal anesthesia with block."
- "A scalene block was given for post-op pain control."
Where's the detailed description of the procedure? The clarification of the provider performing the block? The differentiation between the anesthesia for the surgery and the post-op pain block? Follow these documentation recommendations:
- Clarify which provider delivered the post-op pain service. Who administered the block — the surgeon, the anesthetist or someone else? AMA and CMS differ in their guidelines; verify with each carrier.
- Provide the complete description of the block (what, when, why, where, how and meds used) and ensure it is distinct from the anesthesia for the surgery. Indicate the medication (steroid, neurolytic or anesthetic); specify the method (catheter, ablation or injection); list the site (cervical, thoracic or lumbar); specify temporary versus permanent placement of catheters; and indicate the specific condition or diagnosis.
- Ensure there is separate documentation apart from the op note describing the surgery.
- Suggest the surgeon dictate the reason and medical necessity for the transfer of care to another provider when warranted.
Ultimately, expect that you'll need to verify documentation and provider requirements for carriers that allow separate reporting of post-op pain blocks.
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