Anesthesia Coding Alert

Post-op add-on success hinges on documenting separate service.

When your anesthesiologist provides (and oversees) a patient's postoperative pain management, you might be able to garner extra pay. Check details such as documentation of the request and line placement times to confirm whether you should file a separate claim.

1. Do You Have a Surgeon's Request?

Standard post-op pain management falls under the surgeon's scope of responsibility, according to the Correct Coding Initiative (CCI). If the surgeon believes additional or more involved pain management will be necessary, he can request assistance from an anesthesiologist.

"As with any medical service provided to a patient, the need for an anesthesiologist to provide post-op pain management is determined on a case-by-case basis," says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. "Look for a note or comment on a separate form or in an area of the anesthesia record that indicates the request by the physician."

Tip: The written request does not have to be from the surgeon himself. According to guidelines from the American Society of Anesthesiologists, the anesthesia provider can indicate his or her requested participation in the case if the surgeon doesn't document the request himself.

2. Is the Care Separate From Anesthesia?

Your provider's documentation must show that the regional anesthesia used for post-op management was separate from the anesthesia for surgery. Your provider also cannot use the same mode of administration for general surgical anesthesia to deliver the post-op anesthesia.

"Again, look for some indication via a separate form, note or comment, or area on the anesthesia record that indicates the postoperative care was not the mode of anesthesia," Dennis says.

Payer check: Some payers might require you to append modifier 59 (Distinct procedural service) to the code for post-op management to clarify that it's separate from surgical anesthesia.

3. Do You See Clear Time Notations?

"It's important to clearly show whether the block was placed pre- or postoperatively and billed separately, so that the time involved isn't 'double billed,'" Dennis adds.

"One way to accomplish this is to have an area on the anesthesia record for documenting these items, such as separate boxes for the digital start and stop times of the injection or block," says Tacy Brown, director of billing and compliance with Mountain West Anesthesia in Salt Lake City, Utah. Some payers might require this information to prove that the minutes were not included in the anesthesia time.

Extra tip: If an image for ultrasound guidance is included in the case file, check the time noted on the ultrasound. It should correlate with the documented block or catheter times, Dennis says.

Clear documentation of post-op pain management should include several things:

• Request for post-op pain control
• Procedure performed
• Provider who administered the care
• Catheter site
• Substance injected
• Dosage of the substance
• Time of placement.

Example: An orthopedic surgeon performs a total shoulder replacement. Before the operation, the surgeon requests in writing that your anesthesiologist administer a brachial plexus block via a continuous catheter (64416, Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) for postoperative pain management. Your anesthesiologist places the catheter for post-op care before surgery, noting the time of insertion, medication to be used, and the catheter's purpose. He administers a general anesthetic for the shoulder repair. The catheter remains in place to allow the patient to wake up pain free. You can report 64416 independent of the surgical procedure, thanks to having documentation of the catheter's purpose.

Reference: For an overview of post-op pain management clarifications in the 2012 CCI Coding Guidelines, see Anesthesia Coding Alert, Vol. 14, No. 3.