# Retrobulbar blocks



## consultingbykristin (Jan 14, 2014)

For cataract and other eye cases, the doc is indicating a MAC as well as retrobulbar block.  After doing some checking, it appears to me the block is a combined anesthesia and postoperative pain technique.  My question is...is it separately billable?  If so, what code would be used?  And would modifier 59 be assigned?

Thanks in advance.


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## dwaldman (Jan 14, 2014)

I saw the below on internet search from Supercoder. Although the article is from 2001, their stance stating to report only the anesthesia code seem appropriate since you stated it part for pain management and part as means of anesthesia 

http://www.supercoder.com/coding-ne...ks-is-as-challenging-as-the-procedure-article
Anesthesia Coding Alert



 Coding Retrobulbar Blocks Is as Challenging as the Procedure

- Published on Fri, Jun 01, 2001

Retrobulbar blocks (67500*), which surgeons sometimes request anesthesiologists to administer because theyre riskier than other ocular injections, are pretty 
tricky to code particularly for Medicare and third-party carrier reimbursement. 

Billing 67500* Versus Anesthesia Codes

 Code CPT 67500* appears in the Eye and Ocular Surgery section of the CPT as a stand-alone procedure. I have always followed the rule of thumb that if a block or injection is the anesthesia for a surgical procedure, use the appropriate anesthesia CPT codes  to report it. However, if it is a stand-alone injection or procedure, use the appropriate pain-management, nerve block or injection code instead, says Theresa Ruiz-Law, director of managed care and reimbursement for the American Association of Nurse Anesthetists in Park Ridge, Ill.

Barbara Johnson, CPC, MPC, professional coder with Loma Linda University Anesthesiology Medical Group Inc. of Loma Linda, Calif., says 67500* is used, for example, when an injection block is given to a patient with multiple facial lacerations for pain control. Its also used for unusual complications (such as a sudden increase inblood pressure) that preclude continuing surgery. If the surgery is discontinued after the administration of the retrobulbar block, code the procedure with 67500* to indicate that the injection was for pain management with no further monitoring. 

 In surgical situations, either the surgeon or the anesthesiologist might administer the nerve block. Often, however, the anesthesiologist is still likely to provide patient monitoring as well as additional medication to help calm the patient. Therefore, the anesthesiologist should bill the service with anesthesia codes that accurately reflect the level of care, Johnson says. 

 In this instance, you can bill nerve blocks only for pain management. Ruiz-Law cautions that some managed care companies will lump retrobulbar blocks into the ocular surgery payment. Other carriers consider the blocks local anesthesia and bundle it with the anesthesia code. (If the payment for a block is bundled into the surgical code, it is up to the surgeon and anesthesiologist to negotiate fees.)

 Yet, in the case of eye surgeries most commonly associated with retrobulbar blocks, such as 66984 (extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]), the anesthesiologists role extends far beyond administering the block. Mary Klein, coding specialist with Panhandle Medical Services of Pensacola, Fla., notes that anesthesiologists seldom administer only a retrobulbar block. In our practice, we use the pertinent anesthesia code, such as 00142 (anesthesia for procedures on eye; lens surgery), because it includes patient sedation during surgery and the level of monitoring necessary before, during and after surgery, she says. We rarely use [...]


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## dwaldman (Jan 14, 2014)

Here a later article I found from them when 

http://www.supercoder.com/coding-ne...retrobulbar-blocks-than-meets-the-eye-article


Anesthesia Coding Alert


Team Techniques: There's More to Coding Retrobulbar Blocks Than Meets the Eye

- Published on Wed, Aug 16, 2006


Check these 3 areas before coding your next claim 


Performing eye surgery can be quick and easy (comparatively speaking) for surgeons, but coding your anesthesia providers' work is never cut-and-dried. 

A physician administers a pain block before the eye surgery begins, and a physician or other qualified anesthesia professional monitors the patient during the procedure. Knowing who is involved with each portion of the procedure from an anesthesia standpoint ensures you code correctly. 


Understand What's Happening  


â€œFacilities see a high volume of these cases performed almost exclusively as outpatient procedures,â€� says Darlene Ogbugadu, CPC, an anesthesia coding supervisor with Northwestern Medical Faculty Foundation in Chicago. â€œThey usually involve the administration of a local anesthetic in addition to systemic sedation and blocks administered by the anesthesiologist.â€�

Diagnoses leading to eye surgery can include cataracts (366.xx), glaucoma (365.xx), strabismus (378.xx) and retinal detachment (361.xx). 

â€œRetrobulbar blocks are useful methods of achieving anesthesia for intraocular and orbital surgeries,â€� Ogbugadu adds. â€œThese blocks are good alternatives to general anesthesia when general anesthesia is undesirable or contraindicated.â€� 

Case 1: Anesthesiologist Places the Block, CRNA Observes  


Some facilities prefer to have the anesthesia team handle all aspects of eye surgery anesthesia. If so, the anesthesiologist sometimes places the initial block but assigns a CRNA to observe the case once it begins. 

In years past, some coders in this situation reported the retrobulbar block with 67500 (Retrobulbar injection; medication [separate procedure, does not include supply of medication]) in addition to the procedure's anesthesia. But problems can arise with this stance once the anesthesiologist hands off the care to the CRNA, so many of today's coders don't code the block itself. 

â€œMost carriers consider billing the retrobulbar blocks in addition to the anesthesia time and base units as bundling and not payable,â€� Ogbugadu says. â€œWe do not bill for the block.â€� 

Instead, only report the correct procedure code: 

• 00140 -- Anesthesia for procedures on eye; not otherwise specified 
• 00142 -- â€¦ lens surgery 
• 00144 -- â€¦ corneal transplant 
• 00145 -- â€¦ vitreoretinal surgery.


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## dwaldman (Jan 14, 2014)

The other question I had was CPT 67500 for nerve block or for another type of procedure all together. So if this would fall under a 64XXX series code then you need to look at the NCCI policy manual that states the peripheral nerve block with MAC is not separately  reported, which could also effect the procedure combination you are reviewing.

An epidural or peripheral nerve block injection (code numbers as identified above) administered preoperatively or intraoperatively is not separately reportable for postoperative pain management if the mode of anesthesia for the procedure is monitored anesthesia care (MAC), moderate conscious sedation, regional anesthesia by peripheral nerve block, or other type of anesthesia not identified above.

http://www.cms.gov/Medicare/Coding/N...tEd/index.html


4. Under certain circumstances an anesthesia practitioner may separately report an epidural or peripheral nerve block injection (bolus, intermittent bolus, or continuous infusion) for postoperative pain management when the surgeon requests assistance with postoperative pain management. An epidural injection (CPT code 623XX) for postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode of intraoperative anesthesia is general anesthesia and the adequacy of the intraoperative anesthesia is not dependent on the epidural injection. A peripheral nerve block injection (CPT codes 64XXX)for postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection. An epidural or peripheral nerve block injection (code numbers as identified above) administered preoperatively or intraoperatively is not separately reportable for postoperative pain management if the mode of anesthesia for the procedure is monitored anesthesia care (MAC), moderate conscious sedation, regional anesthesia by peripheral nerve block, or other type of anesthesia not identified above. If an epidural or peripheral nerve block injection (code numbers as identified above) for postoperative pain management is reported separately on the same date of service as an anesthesia 0XXXX code, modifier 59 may be appended to the epidural or peripheral nerve block injection code (code numbers as identified above) to indicate that it was administered for postoperative pain management. An epidural or peripheral nerve block injection (code numbers as identified above) for postoperative pain management in patients receiving general anesthesia, spinal (subarachnoid injection) anesthesia, or regional anesthesia by epidural injection as described above may be administered preoperatively, intraoperatively, or postoperatively.


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