Anesthesia Coding Alert

Bier Blocks Are Common, So Code Them Correctly

Published on Sun Dec 01, 2002

Just because the Bier block is one of the most commonly performed regional anesthesia techniques doesn't mean it's always coded correctly or that coding for it is easy.

But coding for the Bier block also called intravenous regional anesthesia becomes easier if you know what service the anesthesiologist performed. If you combine that with a sound understanding of your carriers' coding preferences, you can successfully code Bier blocks and receive appropriate reimbursement.

Ask Pain Management or Surgical Anesthesia?

Bier blocks use tourniquets to allow targeted anesthesia delivery to an extremity. Using tourniquets means that anesthesia providers typically use Bier blocks for procedures that last less than an hour, says Cindy Clark, anesthesia coding supervisor with the physician group Anesthesiology Consultants in Savannah, Ga. That's so the blood supply isn't cut off too long or the tourniquet pain does not get too severe.

Your first step in correctly coding a Bier block is determining whether it was used during a surgical procedure or for pain management. Consider the following scenarios for times when Bier blocks might be used and how you should code the procedures:

During a wrist ganglion excision The surgical procedure is 25111 (Excision of ganglion, wrist [dorsal or volar]; primary) with diagnosis code ICD-9 727.43 (Ganglion, unspecified). You would report the block with CPT 01810 (Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand) because it is used as anesthesia during surgery.

During surgery to repair a fractured radius Report the anesthesia with 01820 (Anesthesia for all closed procedures on radius, ulna, wrist, or hand bones) if it is a closed repair, or use 01830 (Anesthesia for open procedures on radius, ulna, wrist, or hand bones; not otherwise specified) for an open reduction internal fixation of the bone.

During a pain management procedure for conditions such as reflex sympathetic dystrophy (RSD) When an anesthesia provider administers a Bier block for pain management, report it with 01995 (Regional intravenous administration of local anesthetic agent or other medication [upper or lower extremity]). The purpose of the block in this case is to treat a chronic pain syndrome, not to provide anesthesia for a surgical procedure. Because the block is not an anesthetic, you could use an appropriate E/M code if the patient assessment and procedure are performed on different days. Check with your carrier about coding when the anesthesia provider performs the assessment and procedure on the same day. Some insurers include the E/M visit in the procedure cost, but others don't.

Although an anesthesiologist usually administers Bier blocks, there are times when the surgeon performs the procedure. Opinions vary on which code is most appropriate in such a case. Two possibilities are surgical code 64450* (Injection, anesthetic agent; other peripheral nerve or branch) or anesthesia code 01995 (Regional intravenous administration of local anesthetic agent or other medication [upper or lower extremity]). If the surgeon administers the block to relieve chronic pain, coder Trish Bukauskas, CMM, CPC, owner of TB Consulting in Myrtle Beach, S.C., recommends using 01995 (as when the anesthesiologist administers it). Whether you report the surgical or anesthesia code, the surgeon also appends modifier -47 (Anesthesia by surgeon) to the claim.

Other Codes May Be Considered,But Don't Apply

You may also hear other codes mentioned as possibilities for reporting Bier blocks, but our experts disagree. Here are their reasons for dismissing these codes:

64450* (Injection, anesthetic agent; other peripheral nerve or branch) Clark says the physicians in her group don't think this code describes the procedure, saying that it is not appropriate for an intravenous regional technique such as a Bier block.

90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous) This code (as well as related code 90783, intra-arterial) sometimes confuses coders because the descriptor of 01995 includes the note that For intra-arterial or intravenous therapy for pain management, see 90783, 90784." This note leads some coders to think that 90783 or 90784 should be reported for intra-arterial or intravenous therapy for pain management. But these codes for intravenous injections don't adequately describe the work involved with a nerve block, so they are not appropriate for Bier block coding.

64999 (Unlisted procedure, nervous system) Although unlisted-procedure codes are sometimes needed, they are never a favorite choice. An unlisted-procedure code is rarely needed for reporting a Bier block. Instead, use 01995 for a Bier block administered for pain relief. When the Bier block is part of the surgical anesthetic, use the appropriate anesthesia code based on the procedure performed.

Coding for non-anesthetic Bier blocks is like coding for many other anesthesia procedures it may not be a covered service, or you may need pre-approval for it. Check with your local carrier to ensure that it's a covered service and submit the appropriate codes and documentation based on the carrier's policies. Some carriers (such as workers' compensation) may require pre-approval of services.