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The Economics of Peripheral Nerve Blocks
How to document, bill and actually get paid for regional blocks.
Brian Williams
Publish Date: March 17, 2008   |  Tags:   Anesthesia

Strange but true: Peripheral nerve blocks have been around for more than 50 years, yet many payors still don't reimburse for them in post-operative pain management, arguing that regional anesthesia and blocks are evolving, experimental treatments. Here's advice for overcoming this obstacle so that you're free to use one of the most effective techniques to reduce both pain and the risk of post-op stress syndrome.

Reducing chances of a denied claim
Over the past 12 years at the University of Pittsburgh Medical Center, we've discovered two key things about regional anesthesia:

  • it can save up to 10 minutes of OR time per case when compared with general anesthesia; and
  • it can save $400 to $800 per orthopedic patient when administered in an induction room outside the OR.

Whether you'll be reimbursed for regional depends on a carrier's experience and comfort with these techniques, your geographic location, and how you perform, document and bill for the procedures. A good starting point is to find out if area facilities are reimbursed for blocks. Often when one facility, especially a large one, has made the case for regional anesthesia and block reimbursement, other facilities can piggyback on the precedent.

However, if a certain third-party payor has never reimbursed for regional and blocks in your area, you'll need to show the insurer that blocks work, save time and money, and improve patient outcomes. Many of my publications through the years (which you can find on Medline) may serve as useful evidence when making the case to payors.

A few important points:

  • Don't consider blocks part of the global fee for anesthesia in the surgical procedure. (Note that billing convention would include spinal anesthesia as a "global fee" anesthetic.)
  • It helps when the surgeon requests the block — and you document as such — for acute post-op pain management. This is equivalent to medical necessity documentation.
  • Regardless of whether you administer the block before or after surgery, it's helpful in avoiding claim denials to perform the block outside the OR. If your facility forces you to perform blocks in the OR rather than a block room, be sure not to bill for the OR time if you bill for the block.

Why Two Anesthesia Providers Are Better Than One

To minimize claim denials, the anesthesia provider who administers the block shouldn't be the same one who administers the global anesthesia, but this can vary based on negotiation and dialogue with carriers. If there's only one anesthesia provider, document the procedure as having taken place in a separate location from the global anesthesia (outside the OR). In cases with one anesthesiologist medically directing more than one procedure at a time, a floating provider such as a CRNA, an anesthesia assistant or resident should be in attendance with the anesthesiologist during regional anesthesia and nerve block placement outside the OR. However, the anesthesiologist should not medically direct more than four total locations at once because the physician will then be "supervising," which has a lower reimbursement rate for the global anesthesia fee.

— Brian A. Williams, MD, MBA

Document everything
While your anesthesia delivery should be cutting edge, you should document billing for regional and blocks the old-fashioned way: with hard copies. Since regional and blocks require extra documentation, it's best to create a template form that includes:

  • type of block (distinguish single-injection blocks from continuous nerve block catheters);
  • indications and/or diagnoses such as the 719.XX pain ??????chief complaint'' code;
  • surgeon's request for post-op pain management;
  • description of the procedure;
  • date of the procedure;
  • name and signature of the anesthesia provider;
  • statement that the block was performed pre- or post-anesthesia, if done outside the OR; and
  • whether imaging (ultrasound) was used to facilitate block placement.

Through the years, our group has found that that it's best to bill blocks as a "type 2" service charge modifier, rather than for the time it takes to perform the block. The reimbursement for a charge modifier is usually more than will be recouped when billing for time. However, payors are less likely to refuse time-based billing. In cases when a third-party payer refuses to pay for the block-associated charge modifier, you can successfully bill for time units, using OR-level monitoring and charting, under the concept of "discontinuous billing." That way, physicians receive at least some reimbursement.

When billing for a block, make sure that you unbundle it from the standard global fee for anesthesia. To do this, append modifier -59 to the 5-digit block code. For bilateral procedures, add modifier -50 as well. For multiple blocks on the same extremity, use modifier -51. Adding a second block will commonly decrease reimbursement for the second block by 50 percent, but will also reduce the likelihood of claim denial when compared with billing for both blocks separately. When billing as a charge modifier, don't bill for the time it took to perform the block because that would be double billing.

You'll also need to use an ICD-9 diagnosis code for pain, not the surgical diagnosis. For example, nerve block documentation for billing purposes should refer to "shoulder pain" rather than "torn rotator cuff." Here are some applicable ICD-9 pain diagnosis codes:

  • Shoulder 719.41
  • Hip 719.45
  • Arm (upper) 719.42
  • Thigh, pelvic 719.45
  • Elbow 719.42
  • Knee 719.46
  • Forearm/wrist 719.43
  • Lower leg 719.46
  • Hand 719.44
  • Foot/ankle 719.47

Anesthesia Notebook

Mirtazapine is best known for treating depression. However, it may also be used for treating anxiety or to make people drowsy just before surgery. A study shows that premedication with mirtazapine 30mg reduces the level of preoperative anxiety and the risk of PONV in moderate and high-risk female patients. The study, reported in the January Anesthesia & Analgesia, compared the results of 80 female patients scheduled for gynecological surgery with at least two PONV factors and found that those who were given a 30mg tablet of mirtazapine with 8mg of dexamethasone were far less anxious than the patients who only received dexamethasone. In addition, the treated group had significantly fewer episodes of PONV over the following 24-hour period.

• • •

Pre-operative fasting could cause problems, particularly if the patient is dehydrated before the procedure. A review in December's Current Opinion in Anesthesiology found that patients who were given one liter of fluid for minor procedures or one to three liters for moderate procedures (particularly laparoscopic surgery) improved the patient's well-being before the procedure and their post-op recovery. The study's authors recommended further research on having patients drink carbohydrate-rich beverages before procedures to reduce such negative effects of fasting as hunger and PONV.

• • •

Leaving dentures in a patient's mouth can make bag-mask ventilation easier, according to a study in the August Anesthesia & Analgesia. The common practice is to remove the dentures before a procedure. Yet when researchers compared 84 patients who had their dentures left in to 81 that had theirs removed before receiving anesthesia, they found that bag-mask ventilation was significantly easier when patients had their dentures left in. The researchers recommend dentures should be removed after the airway is secured to prevent damage or accidental swallowing.

— Nathan Hall

Negotiating contracts for PNBs
When negotiating a payor contract, ensure that blocks are unbundled from anesthesia global fees. Create subcategories for single-injection blocks as well as continuous blocks. Many insurers base anesthesia reimbursement on Medicare fee schedules, which historically undervalue anesthesia compared to other services. Set a goal of at least 150 percent of your local Medicare reimbursement. Don't let the payor force you to bundle equipment charges with professional fees. If you're in a freestanding center, avoid the trap that your blocks will be based strictly on a CMS-for-ASC model. Based on CMS templates, hospital-integrated ASCs can get reliably better reimbursement for a wider variety of blocks, both single-injection and continuous, while most of these blocks in freestanding ASCs are relegated to "other peripheral nerve block," which pays far less.

Wherever PNBs are performed in the context of same-day surgery, the facility should be compensated. This isn't always the case. Many facilities don't bill a facility fee, which means that they may be missing out on reimbursement. The facility fee should cover the cost of needles, infusion pumps, nerve stimulators and dressing supplies. Make sure that each type of block (single-injection versus continuous) has its own facility fee code, since the equipment needed for continuous blocks is more expensive than that needed for single-shot blocks.

As with the professional fee, the billing for the facility fee should indicate that the block was administered for post-op pain relief and administered in a dedicated space outside the OR. Billing should also differentiate between single-shot and continuous-infusion blocks.

In 2007, CMS expanded its list of billing codes for blocks in ASCs. Here are facility fee codes for ASCs and hospital-integrated ambulatory units. Also listed with asterisks are PNB billing codes that are available only to CMS patients at hospital-based ambulatory units, not ASCs.

  • 64415 Nerve block injection, brachial plexus
  • 64416 Nerve block continuous infusion, brachial plexus
  • 64417 Nerve block injection, axillary
  • 64418 Nerve block injection, suprascapular nerve
  • 64450 Nerve block, other peripheral nerve
  • *64445 Nerve block injection, sciatic
  • *64446 Nerve block continuous infusion, sciatic
  • *64447 Nerve block injection, femoral or lumbar plexus
  • *64448 Nerve block continuous infusion, femoral
  • *64449 Nerve block continuous infusion, lumbar plexus
  • *64520 Nerve block injection, paravertebral
  • *64999 Nerve block continuous infusion for paravertebral in Pennsylvania. This likely differs by state.

The key point of emphasis is that for a Medicare patient, a freestanding ASC will only be paid for the codes above without asterisks (64415 to 64418 and 64450). In private-payor negotiations, demand that your blocks are reimbursed as if they were performed in a hospital-integrated ambulatory unit (letting you be paid for the asterisk-codes above), and not based only on the over-restrictive CMS guidelines for ASCs. With third-party payors, you don't get what you deserve, you get what you negotiate.

Ultrasound techniques have become increasingly common for locating the nerves before a block. Use code 76942 (ultrasonic guidance for needle placement) for reimbursement. With the proper modifier, you can use the code for the provider's professional fee, as well as for the facility's equipment and supply costs. The billing requirements for ultrasound guidance vary among payors. Some, including some geography-specific Medicare administrators, require hard copy documentation including the request from the ordering physician, the ultrasound report and the sonographer's credentials.

The explanation of benefits details what the payor is paying for and what has been denied. Because of blocks' mystifyingly shaky status among carriers, read the EOB very carefully. Check to see if the procedures that you billed have been paid for according to your contract. If you don't have a contract, verify that you were reimbursed according to the patient's contract.

If denied charges don't have an explanation, appeal the denial. When doing so, include documentation that the procedure was performed according to contract, under the eligible conditions and billed properly as a procedure for pain that is unbundled from the global fee for anesthesia.

More to come
The hospital cost-saving aspects of regional anesthesia and peripheral nerve blocks have become generally accepted among providers, especially when you use a pre-op block area and reduce OR turnover time. Insurers in other markets are not as enlightened. As more anesthesia providers become comfortable with blocks, so will insurance payors. In the meantime, educating payors and documenting thoroughly will be the most effective means of combating the skepticism that currently guides the reimbursement issues in regional anesthesia.