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5 Top Tips for Block Reimbursement
David Auyong, MD, Seattle, Washington
OSD Staff
Publish Date: August 1, 2009   |  Tags:   Anesthesia

August, 2009

VIRTUALLY EVERYONE IN SURGICAL ANESTHESIA now understands the many clinical benefits of peripheral nerve blocks, including the pain relief, decreased opioid use, minimized PONV and improved patient satisfaction. But many of us still do not understand how professionals and the surgical facilities can receive proper compensation for the superior care PNBs provide. The key lies in communicating properly to insurers about the nature of peripheral nerve blocks. Here are some tips for ensuring fair reimbursement for PNBs.

Tip 1: Request a surgeon order for a nerve block for post-operative pain. When an anesthesiologist performs a PNB without a documented request from the surgeon, the insurer may view it as a self-referral. A surgeon???s order ensures that this won???t happen. Be sure the order specifies the intent of the block as post-op pain control/treatment.

Tip 2: Perform blocks outside the OR. Performing the block in a procedure room or preoperative holding area rather than the OR helps insurers understand that this is a separate service from the anesthesia provided for surgery. If blocks must be done in the OR, I recommend documenting the time to perform the blocks and segregate this from billable OR time.

Tip 3: Document the block separately. Rather than recording the PNB in the anesthesia record, document it on a separate piece of paper. This shows that the block is an additional procedure that is not part of the surgical/intraoperative anesthesia regimen.

Tip 4: Bill for post-op analgesia only when that is the block???s primary role. If the block is a primary surgical anesthetic, it is not reimbursable as a treatment for post-op pain even if it performs both functions. For example, if all you do is light sedation during surgery that is covered by a nerve block, the block is a key part of surgical anesthesia and cannot be billed as a treatment for post-op pain. The block qualifies for reimbursement as a post-op pain treatment only when the surgical anesthesia regimen is effective enough to perform the entire procedure without the block (i.e., general or spinal anesthesia, deep sedation with airway intervention such as LMA). The timing of block administration is not relevant. Note that if you use ultrasound guidance, you can bill for this regardless of block function in addition to the post-operative pain billing.

Tip 5: Code the procedure properly. Use the exact CPT code for the specific block performed, and use the diagnosis code for acute postop pain (338.18). In addition, use a modifier to show that the PNB is a distinct service, independent of other services performed. Specifically, use the -59 modifier for PNBs performed without ultrasound guidance and the -26 modifier for ultrasound guidance.

In our area, the Medicare base rate for anesthesia professionals for a block is about $80, and the rate for ultrasound guidance is $30-$35, with private insurers paying about 50 percent more. Facility (technical component) fees are about double the practitioner fee. Clearly, no one will get rich from PNBs, but if these very modest reimbursements can help cover costs, then it will clear the way for more patients, practitioners and facilities to reap the benefits of improved outcomes, greater efficiencies, and better patient satisfaction.

Dr. Auyong completed his regional anesthesia fellowship at Duke and is now a specialist in regional anesthesia with Virginia Mason Regional Medical Center, Seattle, Washington.