# 64450 Denials WPSMedicare(Indiana)



## Melissa*Ever*Evolving (Jan 27, 2014)

Help! I am seeing different types of POST OP PAIN management injections deny.

Saphenous Blocks are denying when billed in both ways. 
64450 with 338.18 & 719.47    OR   64450 with 338.18 & 729.5
  (This is done for post op pain management for a foot procedure)

Obturator Block Denied with post op pain for TKA:
64450 with 338.18 & 719.46

WPS keeps referring my co-worker to LCD L32899.

I understand the codes are used in this LCD, however this is not to treat peripheral neuropathy and should be sent to reconsideration with records but they are still denying.

What should our next step be? WPS has no policy on Post op Pain management.

***They are also taking post-op day management payments back (99231s!) even though it was for post op pain management not a routine post op check.***

Frustrated... and need help!
Thanks for all your input!

~Melissa, CPC


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## mitchellde (Jan 27, 2014)

did your provider also perform the surgery?


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## Melissa*Ever*Evolving (Jan 27, 2014)

No, the provider is an anesthesiologist. They provided the anesthesia for the surgery. 
We apply modifier -59 to any additional post op pain management injections.

~Melissa, CPC


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## dwaldman (Jan 28, 2014)

Will have to appeal. Have you used ICD-9 for acute postoperative pain as primary then the location of the pain, I am not sure if this would prevent the it hitting for peripheral neuoropathy due underlying systemic diseases. I noticed WPS Medicare J5 is revising and it is the draft stage.


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## drakena74 (Apr 7, 2014)

I do know that Medicare does NOT pay for post op pain injections when even if it was performed by an Anesthesiologist.  It's considered bundled into the primary surgical procedure.  Check your Medicar NCCI edits.


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## hgolfos (Apr 7, 2014)

Since when does Medicare not pay for post op pain?  Up until now they have explicitly stated in the NCCI manual that post operative pain management injections are billable provided that the primary reason for the block is for postoperative pain relief and not for anesthetic.  We've never had a problem until now, we are seeing similar denials.


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## hgolfos (Apr 7, 2014)

The below is from the NCCI Manual, chapter 2 pages 6-11

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.
Revision Date (Medicare): 1/1/2014
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5. If an epidural or subarachnoid injection (bolus, intermittent bolus, or continuous) is utilized for intraoperative anesthesia and postoperative pain management, CPT code 01996 (daily hospital management of epidural or subarachnoid continuous drug administration) is not separately reportable on the day of insertion of the epidural or subarachnoid catheter. CPT code 01996 may only be reported for management for days subsequent to the date of insertion of the epidural or subarachnoid catheter.
6. Anesthesia HCPCS/CPT codes include all services integral to the anesthesia procedure such as preparation, monitoring, intra-operative care, and post-operative care until the patient is released by the anesthesia practitioner to the care of another physician. Examples of integral services include, but are not limited to, the following:
• Transporting, positioning, prepping, draping of the patient for satisfactory anesthesia induction/surgical procedures.
• Placement of external devices including, but not limited to, those for cardiac monitoring, oximetry, capnography, temperature monitoring, EEG, CNS evoked responses (e.g., BSER), Doppler flow.
• Placement of peripheral intravenous lines for fluid and medication administration.
• Placement of airway (e.g., endotracheal tube, orotracheal tube).
• Laryngoscopy (direct or endoscopic) for placement of airway (e.g., endotracheal tube).
• Placement of naso-gastric or oro-gastric tube.
• Intra-operative interpretation of monitored functions (e.g., blood pressure, heart rate, respirations, oximetry, capnography, temperature, EEG, BSER, Doppler flow, CNS pressure).
• Interpretation of laboratory determinations (e.g., arterial blood gases such as pH, pO2, pCO2, bicarbonate, CBC, blood chemistries, lactate) by the anesthesiologist/CRNA.
• Nerve stimulation for determination of level of paralysis or localization of nerve(s). (Codes for EMG services are for diagnostic purposes for nerve
Revision Date (Medicare): 1/1/2014
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dysfunction. To report these codes a complete diagnostic report must be present in the medical record.)
• Insertion of urinary bladder catheter.
• Blood sample procurement through existing lines or requiring venipuncture or arterial puncture.
The NCCI contains many edits bundling standard preparation, monitoring, and procedural services into anesthesia CPT codes. Although some of these services may never be reported on the same date of service as an anesthesia service, many of these services could be provided at a separate patient encounter unrelated to the anesthesia service on the same date of service. Providers may utilize modifier 59 to bypass the edits under these circumstances.
CPT codes describing services that are integral to an anesthesia service include, but are not limited to, the following:
• 31505, 31515, 31527 (Laryngoscopy) (Laryngoscopy codes describe diagnostic or surgical services.)
• 31622, 31645, 31646 (Bronchoscopy)
• 36000, 36010-36015 (Introduction of needle or catheter)
• 36400-36440 (Venipuncture and transfusion)
• 62310-62311, 62318-62319 (Epidural or subarachnoid injections of diagnostic or therapeutic substance - bolus, intermittent bolus, or continuous infusion)
CPT codes 62310-62311 and 62318-62319 (Epidural or subarachnoid injections of diagnostic or therapeutic substance - bolus, intermittent bolus, or continuous infusion) may be reported on the date of surgery if performed for postoperative pain management rather than as the means for providing the regional block for the surgical procedure. If a narcotic or other analgesic is injected postoperatively through the same catheter as the anesthetic agent, CPT codes 62310-62319 should not be reported for postoperative pain management. An epidural injection for postoperative pain management may be separately reportable with an anesthesia 0XXXX code only if the patient receives a general anesthetic and the adequacy of the intraoperative anesthesia is
Revision Date (Medicare): 1/1/2014
II-9
not dependent on the epidural injection. If an epidural injection is not utilized for operative anesthesia but is utilized for postoperative pain management, modifier 59 may be reported to indicate that the epidural injection was performed for postoperative pain management rather than intraoperative pain management.
Pain management performed by an anesthesia practitioner after the postoperative anesthesia care period terminates may be separately reportable. However, postoperative pain management by the physician performing a surgical procedure is not separately reportable by that physician. Postoperative pain management is included in the global surgical package.
Example: A patient has an epidural block with sedation and monitoring for arthroscopic knee surgery. The anesthesia practitioner reports CPT code 01382 (Anesthesia for diagnostic arthroscopic procedures of knee joint). The epidural catheter is left in place for postoperative pain management. The anesthesia practitioner should not also report CPT codes 62311 or 62319 (epidural/subarachnoid injection of diagnostic or therapeutic substance), or 01996 (daily management of epidural) on the date of surgery. CPT code 01996 may be reported with one unit of service per day on subsequent days until the catheter is removed. On the other hand, if the anesthesia practitioner performed general anesthesia reported as CPT code 01382 and at the request of the operating physician inserted an epidural catheter for treatment of anticipated postoperative pain, the anesthesia practitioner may report CPT code 62319-59 indicating that this is a separate service from the anesthesia service. In this instance, the service is separately reportable whether the catheter is placed before, during, or after the surgery. Since treatment of postoperative pain is included in the global surgical package, the operating physician may request the assistance of the anesthesia practitioner if the degree of postoperative pain is expected to exceed the skills and experience of the operating physician to manage it. If the epidural catheter was placed on a different date than the surgery, modifier 59 would not be necessary. Effective January 1, 2004, daily hospital management of
Revision Date (Medicare): 1/1/2014
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continuous epidural or subarachnoid drug administration performed on the day(s) subsequent to the placement of an epidural or subarachnoid catheter (CPT codes 62318-62319) may be reported as CPT code 01996.
• 64400-64530 (Peripheral nerve blocks – bolus injection or continuous infusion)
CPT codes 64400-64530 (Peripheral nerve blocks – bolus injection or continuous infusion) may be reported on the date of surgery if performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block. Peripheral nerve block codes should not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique. Modifier 59 may be utilized to indicate that a peripheral nerve block injection was performed for postoperative pain management, rather than intraoperative anesthesia, and a procedure note should be included in the medical record.
• 67500 (Retrobulbar injection)
• 81000-81015, 82013, 82205, 82270, 82271(Performance and interpretation of laboratory tests)
• 43753, 43754, 43755 (Esophageal, gastric intubation)
• 92511-92520, 92543 (Special otorhinolaryngologic services)
• 92950 (Cardiopulmonary resuscitation)
• 92953 (Temporary transcutaneous pacemaker)
• 92960, 92961 (Cardioversion)
• 93000-93010 (Electrocardiography)
• 93040-93042 (Electrocardiography)
• 93303-93308 (Transthoracic echocardiography when utilized for monitoring purposes) However, when performed for diagnostic purposes with documentation including a formal report, this service may be
Revision Date (Medicare): 1/1/2014
II-11
considered a significant, separately identifiable, and separately reportable service.
• 93312-93317 (Transesophageal echocardiography when utilized for monitoring purposes) However, when performed for diagnostic purposes with documentation including a formal report, this service may be considered a significant, separately identifiable, and separately reportable service.
• 93318 (Transesophageal echocardiography for monitoring purposes)
• 93561-93562 (Indicator dilution studies)
• 93701 (Thoracic electrical bioimpedance)
• 93922-93981 (Extremity or visceral arterial or venous vascular studies) However, when performed diagnostically with a formal report, this service may be considered a significant, separately identifiable, and if medically necessary, a separately reportable service.
• 94640(Inhalation/IPPB treatments)
• 94002-94004, 94660-94662 (Ventilation management/CPAP services) If these services are performed during a surgical procedure, they are included in the anesthesia service. These services may be separately reportable if performed by the anesthesia practitioner after post-operative care has been transferred to another physician by the anesthesia practitioner. Modifier 59 may be reported to indicate that these services are separately reportable. For example, if an anesthesia practitioner who provided anesthesia for a procedure initiates ventilation management in a post-operative recovery area prior to transfer of care to another physician, CPT codes 94002-94003 should not be reported for this service since it is included in the anesthesia procedure package. However, if the anesthesia practitioner transfers care to another physician and is called back to initiate ventilation because of a change in the patient’s status, the initiation of ventilation may be separately reportable.
• 94664 (Inhalations)
• 94680-94690, 94770 (Expired gas analysis)


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## missyah20 (Apr 18, 2014)

Hello - I have the same issue for my Iowa CRNAs.  Here is the issue - WPS Medicare has an LCD (L32899 for Indiana) that is for Nerve Blocks for Peripheral Neuropathy.  Now the procedure code listed in this LCD is 64450 so because dx code 338.18 is not listed on this LCD these post-op pain injections are denying. 

I have been sending redeterminations into WPS noting that these blocks were not performed for peripheral neuropathy, but for post-op pain management and should not be subject to this LCD. 

Good Luck!


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