Anesthesia Coding Alert

The reimbursement process for post-op blocks administered to manage the pain that follows a procedure can be eased by requesting precertification from the insurance carrier.

This type of block falls in a gray area where billing is concerned, says Linda Delancey, office manager for Westside Anesthesia and Pain Management in Wichita, Kan. Do you include it in the global fee, or charge it as an add-on service later?

Jann Lienhard at Cash Flow Solutions, a medical billing agency in Lakewood, N.J., says they bill the blocks as code 64450* (injection, anesthetic agent; other peripheral nerve or branch). Its a medical procedure, so we bill it this way. We list the specific type of block as a separate line item, she adds.

Lienhard and Delancey say that if they bill the procedure with 64450*, they also include a line comment to explain what the block was and why it was used. For example, Ill submit it with the explanation femoral block for post-op pain, Lienhard says. Ive also found that Medicare will pay for it with the -59 modifier (distinct procedural service), so Ive adjusted my billing software to include it with the claim when its appropriate to bill that way.

Some coders might think the claims tend to get too complicated or seem confusing since the block may be submitted on the same claim as the original procedures anesthesia. Lienhard has submitted claims both wayswith both anesthetics on the same claim, and with them filed separately. She found minimal difference in the way the claims were processed, but advises coders to check with their local carriers for a preference.

Post-Op Blocks for Pain Management

Procedures that may be followed by post-op blocks include arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction (29888), arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee replacement) (27447) and arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) (29880). The block prevents the patient from feeling pain for up to twelve or fourteen hours after surgery. The intravenous (IV) is usually set up as part of the pre-op procedures; the block itself is administered before or after the surgery and takes effect in about thirty seconds.

Lienhard and Delancey say one advantage to administering post-op blocks for pain management is that the doctor uses less anesthetic when the block is administered because the patient is already anesthetized for the procedure itself.

Other Steps to Success

Both coders agree that the easiest way to get a post-op block through the reimbursement system is to have the surgeon request it when he or she precertifies the case with the insurance carrier. Lienhard acknowledges that this requires a close working relationship between the surgical and anesthesia teams.

If a request for the block is not made prior to the procedure, Lienhard says that all is not lost. If a block slips by and isnt precertified, I call the insurance carrier afterward. Once I explain the procedure, Im usually successful in getting it added to the initial authorization. Its always worth asking for.

An operative report documenting the blocks administration is crucial for reimbursement. Lienhard says some physicians simply fill in the blanks on a standard form, but others tape a quick dictation that can be transcribed later. The physicians Delancey works with complete a separate operative report for the block.

Although many carriers will reimburse for post-op blocks, the level of payment can vary from carrier to carrier, or even within a carriers system. Lienhard says a carrier might pay 100 percent of the billed rate for one patient, yet pay minimal reimbursement or deny payment for another patient. She admits that it is frustrating, but encourages coders to file the claims whenever appropriate. Pain management is still an evolving area of anesthesia, and lots of reimbursement issues are still being decided. The only way we can get reimbursed down the road is to keep asking for it now.