Anesthesia Coding Alert

Try these surefire coding strategies

Think you're coding brachial plexus blocks correctly?  Read on to learn if you're coding correctly and up-to-date on potential new techniques for BP blocks.

Understand Why Docs Use BP Blocks

Anesthesiologists often administer brachial plexus blocks for one of three reasons: to help ease post-surgical pain, for pain management purposes, or for surgical anesthesia.
 

Postsurgical injections block nerves for a few hours after surgery so the patient doesn't wake up in pain from an upper-extremity or shoulder surgery. These blocks work best for minimally invasive procedures like arthroscopic or simple open repairs, says Robin Fuqua, CPIC, anesthesia coder for Jose Veliz, MD, in Escondido, Calif. More complicated procedures such as total shoulder replacement usually require multi-day analgesics, which can include PCA (patient-controlled analgesia) management over several days instead of a single injection.
 

Chronic pain management injections block nerves from communicating pain in the area when there seems to be no physiologic reason for continuing pain (usually after a traumatic injury was treated and should be healed). "Sometimes, just making the nerves stop sending pain signals for a while 'resets' them so after the drug wears off, they send less severe or no signals of pain," Fuqua says.

Look at Administration Technique First

The brachial plexus is part of the last four cervical and first thoracic vertebrae, and it branches off to the main nerves of the shoulders, chest and arms.
 
Anesthesiologists typically report CPT 64415* (Injection, anesthetic agent; brachial plexus, single) or 64416 (... brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) for brachial plexus blocks with anesthetic agents. Determine whether the physician placed a catheter or performed a single injection for postoperative pain and administered general anesthesia, or whether the physician provided anesthesia with the brachial plexus block.
 
Now you can report continuous infusion blocks more accurately, thanks to the addition of 64416 in CPT Codes 2003. Prior to this, some physicians reported 64415 for each day, but this was misleading since it implied that the physician administered a new block daily. Other physicians reported a subsequent hospital visit code or other E/M code reflecting the level of service.
 
Report injections of neurolytic agents with 64613 (Chemodenervation of muscle[s]; cervical spinal muscle[s] [e.g., for spasmodic torticollis]) or 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). Physicians are especially careful about administering neurolytic agents because they permanently damage the nerve, so you should be just as careful about reporting the most accurate code.
 
Code 64416 has a 10-day global period, which means you don't code separately for any services performed during that period that are related to the original brachial plexus insertion. The code also includes the services provided for daily management of continuous drug administration to the brachial plexus for post-op pain control or chemical sympathectomy. That means you don't report 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) for these postoperative treatments because the block code includes daily management.

Keep Up With New Tactics Under Study

Researchers are always investigating new treatments and modalities in all areas of medicine. Scientists are studying several areas related to brachial plexus blocks, from better ways to administer them to ways to make their effects last longer. Here's the lowdown on two techniques physicians are studying and whether they would change how you code the case.
 

Continued infusions to boost the effects of a brachial plexus block: Regional anesthesia is good for upper-extremity surgery because of advantages such as improved analgesia and reduced side effects. But many of these advantages are lost once the block wears off. Some physicians have started administering continuous ambulatory local anesthetic infusions to help make the benefits of brachial plexus (and other) blocks last longer.
 
Code 64416 still applies to the original block. It has a 10-day global period, which means you wouldn't code separately for follow-up administration during that period. "Most catheters would be out by then," says Scott Groudine, MD, an Albany, N.Y., anesthesiologist. He believes this technique might have limited use, but says the potential for significant complications at home limits its feasibility.
 

Using ultrasound and electrical stimulation for brachial plexus blocks: Finding the correct nerve to treat can be frustrating and time-consuming for the anesthesiologist since current brachial plexus block techniques are "blind." Some studies are under way for using high-resolution ultrasound probe (up to 12 MHz) to identify the brachial plexus in five locations of the upper extremity and to guide needle advancement to the target before nerve stimulation.
 
"Inserting a brachial plexus block doesn't require ultrasound," Groudine says. "Currently, everyone uses electrostimulation of the nerves (without ultrasound) to confirm needle placement." He adds that while ultrasonic guidance is slowly gaining acceptance in some practices for central line insertion, you don't bill anything extra for it. "Ultrasound involves an expensive machine that requires sterility and an extra pair of hands to operate it while the anesthesiologist handles the needle," he says. "Most anesthesiologists have a high level of success without the additional machinery, time and cost this approach might require."
 
Coding brachial plexus blocks will continue to be a common part of your job as physicians continue to find new and better ways to administer them for various cases. Focus on the physician's administration technique and other factors to continue coding them correctly.