Revenue Cycle Insider

Find some expert tips for coding anesthesia pain management services.

Acute postoperative pain management (POPM) remains a hot topic, especially for new anesthesia coders. In 2013, approximately 80 percent of patients experienced postoperative (or acute) pain after surgery, and if you use a search engine to check, the same is still true. However, billing for these often-used services can sometimes be confusing.

POPM is a team effort between the surgeon and the anesthesia provider to assist patients with both expected and unexpected pain after surgery. The major changes to POPM in the National Correct Coding Initiative (NCCI) Policy Manual’s Anesthesia Services section, found in Chapter II from 2013 are ancient history now, although this particular section of the current NCCI is still where most insurance companies look for payer guidance.

Rely On These Resources and Tools

Knowing how to navigate the resources at hand is a big part of finding — and following — the appropriate guidelines.

Top tip: A time-saving hint here: Use the “find” function to search the word “pain” to get to each section related to POPM. For example, Page II-5 explains, “If permitted by state law, anesthesia practitioners may separately report significant, separately identifiable postoperative management services after the anesthesia service time ends.” This verbiage can be confusing based on the wording, which should not be taken literally to mean that only POPM provided after the anesthesia service time ends is billable. Further clarification is found in the following pages with up-to-date codes and examples. Whenever NCCI updates are made, they are identified by a red font, which makes it easier to keep up-to date with changes.

Paragraphs four and five outline circumstances in which POPM is separately paid, ensuring “the mode of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the intraoperative anesthesia is not dependent on the peripheral nerve block injection.” This paragraph does not specifically mention catheters, although the same guidance holds true for a continuous catheter. POPM may be administered “preoperatively, intraoperatively, or postoperatively” as long as it was not the mode of anesthesia for the surgery — which is very clear if the service is provided postoperatively!

When the mode of anesthesia for the procedure is monitored anesthesia care (MAC), conscious sedation, or regional anesthesia, and “the adequacy of the intraoperative anesthesia is dependent on the block or catheter placed pre- or intraoperatively, the block or catheter cannot be reported separately, although discontinuous time can be captured when properly documented,” NCCI says.

Discontinuous time is explained in the section prior to POPM as “the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.” When the block or catheter is not separately billed, the documented time it takes to provide this ancillary service is billable time if there is a gap between when the service was provided and anesthesia start time. The second paragraph on page II-6 emphasizes the requirement of documentation from the surgeon requesting assistance from an anesthesia provider, which payers use as a reason for denying separate payment for POPM.  

Take Note of LCDs

Not all states have local coverage determinations (LCDs) or billing articles for POPM and the states that have LCDs may differ. Noridian’s LCD is related to nerve blockade treatment of chronic (not acute) pain. States with published LCDs for acute pain are First Coast Service Options (FCSO), under Peripheral Nerve Blocks (PNB) L33933; National Government Services (NGS), under PNB L36850; and Palmetto, under Continuous Peripheral Nerve Blocks (CPNB) L37641.

On the bottom page of each of these LCDs there are links to the billing and coding articles, as well as a response to comments section. If you think comment periods aren’t important, think again! POPM documentation requirements were made less stringent based on a comment given before the deadline in 2017. Whether your state has an LCD or not, you can count on Medicare and other payers to look at the NCCI for payment guidance. LCDs related to epidural steroid injections (ESIs) specifically exclude postoperative pain management.

Know the Relevant Bundling, Documentation Rules

NCCI information is based on the Centers for Medicare and Medicaid Services (CMS) Medicare Claim Processing Manual, Chapter 12: Physicians/Non-Physician Practitioners premise that postsurgical pain management by the surgeon is included in the global surgical package. However, the NCCI recognizes the ability of the surgeon to “request the assistance of the anesthesia practitioner if it requires techniques beyond the experience of the operating physician.”

Although postoperative pain is the responsibility of the surgeon and payment is bundled into the surgeon’s global fee, anesthesia services may be reported separately if the services are requested by the surgeon for an anesthesia practitioner to provide POPM and it is clear that anesthesia for the surgical procedure was not dependent on the regional anesthetic technique.

The American Society of Anesthesiologists’ (ASA) Statement on Reporting Postoperative Pain Procedures in Conjunction with Anesthesia indicates “the following conditions apply: 1) Anesthesia for the surgical procedure was not dependent upon the efficacy of the regional anesthetic technique; and 2) The time spent on pre- or postoperative placement of the block is not included in reported anesthetic time” with clarification that “time spent performing the block is not deducted from the total anesthesia time” for a postsurgical block that occurs after induction and prior to emergence.

The ASA also recommends documenting the surgeon’s request, as payers may require specific documentation. According to the NCCI, the “surgeon is responsible to document in the medical record the reason care is being referred to the anesthesia practitioner.” This provision requires a written request from the surgeon — which indicates there must be communication between anesthesia and surgical staff to ensure the requirements for POPM are well documented for each patient on a case-by-case basis.

Check back next month for specifics on the coding the relevant procedures.

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPMA, CPC, CPC-I, Perfect Office Solutions