# Block for Knee Replacement



## aschaeve (Mar 6, 2012)

I have a provider that would like to bill a Continuous Femoral block 64448 and a Sciatic single nerve block 64445 for a total knee replacement.  They are not bundled in CCI, but I am wondering if anyone else is doing this and getting paid.

Thank you,

Alicia, CPC


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## cindyt (Mar 6, 2012)

We bill for this a lot and receive payment.  We append the modifier 59 to each block.


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## aschaeve (Mar 6, 2012)

Thank you,

Alicia, CPC


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## dwaldman (Mar 7, 2012)

The only thing that came to my mind is that the examples they give is post op pain block when performed when the patient is having general anesthesia. They don't give other examples.

AMA CPT AssistantOctober 2001 page 9

Coding Clarification:Anesthesia and Postoperative Pain Management



The following article builds on information originally presented in the February 1997 CPT Assistant article, "Anesthesia: Coding for Procedural Services." 



Codes for procedures commonly used in the management of postoperative pain include 62318 and 62319 (both introduced in CPT 2000) for continuous epidural analgesia and the series of codes for somatic nerve blocks (64400-64450). 



*It is appropriate to report pain management procedures, including the insertion of an epidural catheter or the performance of a nerve block, for postoperative analgesia separately from the administration of a general anesthetic. * 
*When general anesthesia is administered and these injections are performed to provide postoperative analgesia, they are separate and distinct services and are reported in addition to the anesthesia code. Whether the block procedure (insertion of catheter; injection of narcotic or local anesthetic agent) occurs preoperatively, postoperatively, or during the procedure is immaterial. * 

If, on the other hand, the block procedure is used primarily for the anesthesia itself, the service should be reported using the anesthesia code alone. In a combined epidural/general anesthetic, the block cannot be reported separately. 



Examples



 A patient having total knee replacement surgery may receive a regional anesthetic and a postoperative pain management agent through the same epidural catheter, in which case the only code reported would be 01402. 



 A femoral nerve block (64450) placed to provide post-operative analgesia for an anterior cruciate ligament repair or a total knee replacement would be reported separately from the surgical anesthesia. 



 A patient undergoing a thoracotomy might receive an epidural injection of a local anesthetic and/or narcotic (62318) for postoperative pain control in addition to the general anesthetic, which is administered through an endotracheal tube (00540). In this case, the epidural is not the surgical anesthetic and it would be reported separately, as an independent procedure. 



 Shoulder surgery could be performed under an interscalene brachial plexus block that would also provide postoperative analgesia. This would be reported using the anesthetic code (eg, 01620). If the block were intended primarily to alleviate postsurgical pain, and a general anesthetic was administered for the shoulder procedure, the block would be separately reportable using code 64415. 

___________________________________________________________

64400-64530 (Nerve blocks)

CPT codes 64400-64530 (Nerve blocks) may be reported on the date of surgery if performed for postoperative pain management. 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 nerve block injection was performed for postoperative pain management, rather than intraoperative anesthesia, and a procedure note should be included in the medical record.



“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.





 A brachial plexus block might also provide both the anesthesia and the postoperative pain control for an open reduction of a wrist fracture. Only the anesthesia code would be reported.


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## dwaldman (Mar 7, 2012)

Disregard my previous post, I misunderstood your question.


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## Billing500 (Feb 25, 2014)

Are you getting paid in full by insurers or 64445 at 100% and 64448 at 50% due to multiple procedures?  We've been taking a 50% "hit" on the higher-valued continuous femoral nerve block.


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## dwaldman (Feb 25, 2014)

Are you placing modifier 51 on the code with the lower RVU.


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## Billing500 (Feb 28, 2014)

I've seen so many variations of RVUs.  Some state that 64448 is actually higher in RVU vs 64445 while I've seen other sources that show the opposite.  Is there a CMS master listing?  
We typically bill a "00" anesthesia code with two blocks.  both blocks have 59 modifiers attached to designate them as post-op pain control.  Can we bill:
00xxx 
64448-59
64445-51

Thanks for your help,
Brian


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## mhstrauss (Feb 28, 2014)

Billing500 said:


> I've seen so many variations of RVUs.  Some state that 64448 is actually higher in RVU vs 64445 while I've seen other sources that show the opposite.  Is there a CMS master listing?
> We typically bill a "00" anesthesia code with two blocks.  both blocks have 59 modifiers attached to designate them as post-op pain control.  Can we bill:
> 00xxx
> 64448-59
> ...



Here is the link to the CMS Files, by year:

http://www.cms.gov/Medicare/Medicar...ysicianFeeSched/PFS-Relative-Value-Files.html

I believe the differences you are seeing are due to POS.  A procedure's facility RVU's are typically lower than a procedure's non-facility RVU's, so make sure you are checking the correct column when looking these up.

Hope this helps!


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## Billing500 (Feb 28, 2014)

Thanks, Meagan.  I've reviewed the spreadsheets.

The work rvu for 64448 is 1.63 while 64445 is 1.48.
The shift comes when you factor in the PE and ME, oddly, 64448 becomes the lowered valued code!  Clinically, this is hard to wrap my hands around.

Despite CMS' RVU designation, would we be denied if we coded the claim as follows (in an effort to get paid 100% on 64448 and 50% on 64445)?
00xxx - Anesthesia Code
64448-59
64445-51

Thanks again for your helpful feedback.


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## mhstrauss (Feb 28, 2014)

Billing500 said:


> Thanks, Meagan.  I've reviewed the spreadsheets.
> 
> The work rvu for 64448 is 1.63 while 64445 is 1.48.
> The shift comes when you factor in the PE and ME, oddly, 64448 becomes the lowered valued code!  Clinically, this is hard to wrap my hands around.
> ...




Now I'm confused! I didn't look at the RVU's for these 2 codes in detail when I answered previously, but looking at them now, you're right; this seems backwards.  However, the way you have the codes listed above, seems to be the correct ranking to get the highest reimbursement, based on the total RVU's.  Just curious, are these procedures done in a clinic or facility?


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## Billing500 (Mar 1, 2014)

They're done in a hospital setting, as part of a TKR, for example.  I'm dumbfounded that CMS would assign a sciatic nerve block with a higher [total] rvu than a continuous femoral block, which is more complicated, etc.

McKesson Clear Claim Connection states that adding both 51 and 59 modifiers to the 64445 code will bump the 64448-59 code to pay at 100% while 64445 is paid at 50%.  Will give it a shot.

Thanks again!


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