First my aplogies for not includint this with your month end reports. Approximately 60 plus days ago some 300,000 plus CCI edits were updated. Hiden inside shows the vast majority of the new edits show nerve block and anestheic injection codes bundled into most surgical procedures. We believe the precursor to the CCI edits was from a local carrier determiniation.
First Coast Service Options, which holds the J9 jurisdiction Medicare administrative contract (J9 MAC) covering Florida, Puerto Rico and the Virgin Islands, released an LCD recently stating that “preemptive nerve blocks are not separately payable when done by the surgeon or the anesthesia professional who provides the anesthesia/analgesia for the procedure.” The decision became effective Feb. 2, 2009, and includes nerve block procedures performed on the peripheral nervous system – codes 64400-64450.
The determination seems to run contrary to a recent report issued by the American Society of Anesthesiologists (ASA) which states a “provider may bill for a regional anesthetic technique as a service separate from the anesthetic if the regional technique is employed primarily for postoperative analgesia and if the following two conditions apply:
- The anesthesia for the surgical procedure was not dependent upon the efficacy of the regional anesthetic technique. For example, if an interscalene nerve block is placed prior to shoulder surgery to [a]ffect prolonged postoperative analgesia, then a general anesthetic would have to be used for the actual shoulder surgery rather than simply I.V. sedation in order to properly report the regional block separately. In this setting, if the patient was provided a block and only sedation was added, then it would be clear that the interscalene block was a part of the primary anesthetic rather than a mode of postoperative analgesia.
- The time spent on pre- or postoperative placement of the block is separated and clearly not included in reported anesthetic time. Postoperative pain blocks are most frequently placed before anesthesia induction or after anesthesia emergence. When the block is placed before anesthesia time starts or after it has ended, the time spent placing the block should not be included in reported anesthesia time; this is true irrespective of what level of sedation and monitoring is provided to the patient during that block placement. In the less common circumstance where a block is placed during a general anesthetic, time does not need to be deducted as the full anesthesia service is still being performed.”
The decision by First Coast seems all the more perplexing since the report from the ASA directly addresses the issue of bundling post-op pain procedures with surgical procedures: “ASA has recently received reports of payers inappropriately bundling the placement of epidurals and peripheral nerve blocks for postoperative pain control into the payments for surgical anesthesia services. This is contrary to CPT guidance, CCI edits, Medicare contractors’ instructions and the process used to assign base unit values to anesthesia codes… [T]he question of regional anesthetic procedures for postoperative pain relief has been addressed multiple times by the AMA in its coding guide, CPT Assistant. The message has always been consistent: when a pain relief procedure does not serve to deliver the primary anesthetic for a surgical procedure, it is separately reportable from an anesthesia service.”
What you can do
Even with the backing of the ASA, it may be difficult to convince the payer to cover post-op pain block services. Joanne Mehmert, CPC, president of Mehmert and Associates, LLC in Kansas City, Mo., recommends practices try to apply the pressure of their local pain and anesthesia society or try to get the backing of a national organization such as the American Society of Interventional Pain Physicians (ASIPP). “The Blue in Michigan tried to stop paying for POP nerve blocks a few years ago and the MI Anesthesia Society had quite a battle with them and prevailed. It took a few hot letters and I’m sure some meetings took place – but the blocks are getting paid,” she notes.
Documentation of medical necessity is key
The First Coast LCD does state a separate physician may still perform and bill for peripheral nerve blocks administered for post-op pain but “[w]hen 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.”
If you do try to bill for the post-op pain block performed by a separate physician, make sure you are careful to document medical necessity. Again, ASA offers some recommendations:
“One excellent means of portraying that the block was a postoperative analgesic is to dictate or record its conduct in the chart in a location separate from the anesthetic record. When documenting, it is important to discuss that the surgeon requested that the anesthesia team participate in the provision of postoperative analgesia, that the patient was involved in the process of defining the best plan for such analgesia and that the patient received additional information about the risks and procedures of such therapy and consented to the procedure, separate from the information attendant to informed consent for the anesthetic.”
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Editor: Philip Blann (pblann@anesthesiabilling.com).
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