Anesthesia Coding Alert

Pain-Free Payments:

Investigating Details Helps You Get Paid for Post-Op Pain Epidurals

Published on Tue Feb 08, 2005

Check these 5 areas to help claims through the process

It happens all the time - so often, in fact, that many coders probably don't think twice about how to report postoperative pain epidurals. The mind-set changes, however, when a carrier suddenly stops paying for the service but doesn't explain why. That's when it's time to re-evaluate your coding game plan to check whether the problem is on your side of the process - and to know how to fix it.

Start With Request and TOS

Surgeons typically request post-op pain epidurals for patients following cardiac surgery, joint replacement or other complex procedures, says Cindy Clark, anesthesia coding supervisor with the physician group Anesthesiology Consultants in Savannah, Ga. Because the pain practitioner only provides the service at the surgeon's request, be sure your physician documents that request - in writing - and includes it in the patient's medical record.

Another up-front detail to consider is whether you're reporting the correct type of service (TOS). Be sure to bill the initial surgery's anesthesia as TOS 7 (Anesthesia service) and the post-op pain service as TOS 2 (Surgical service). If the same physician handles both services, some coders recommend filing two separate claims to differentiate the procedures.

Investigate the Catheter's Use

Verify with the pain physician whether he placed the patient's catheter for use during the surgery or solely for post-op pain management. If he used the catheter to provide anesthesia during the procedure, you cannot separately report its use for post-op pain relief on that same day.

Some coders wonder if they can add the catheter's insertion time for additional reimbursement, but coders such as Donna Howe with Anesthesiology Consultants of Eastern Connecticut in Manchester don't recommend it. Reasoning: "Aetna doesn't pay for post-op pain control, and they have told us we may not add the insertion time," she says. "It might be an individual carrier issue, but we find that trying to add the time messes up our concurrency program, so we don't do it."

If the physician placed the catheter for post-op management after the procedure, you can report 62319 (Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) for the first day's care. Append modifier -59 (Distinct procedural service) to show that this catheter placement and management are separate from the surgery.

Adequately Document Medical Necessity

When you append modifier -59 to 62319, be sure to include documentation for the post-op block.

"Our local Medicare carrier wants only one diagnosis code, so we don't include the diagnosis for the original surgery," Howe says.

Other carriers, however, might require several different diagnoses to justify medical necessity:

Report pain for the primary diagnosis supporting the block's use. The correct diagnosis will depend on each individual case; the code should describe the type of pain and should explain why the physician placed the pain block.

Report V45.89 (Other postprocedural status; other) as your secondary diagnosis (this represents the surgery).

Report the appropriate diagnosis code for the original surgery. Again, the actual code will depend on the procedure performed.

Some carriers (such as Blue Cross Blue Shield of Georgia) might require V58.49 (Other specified aftercare following surgery) or another code as a secondary diagnosis instead of a code that represents the site of pain. This might seem strange on the surface, considering that V58.49 is much more general than diagnosis codes such as V54.81 (Aftercare following joint replacement), but Clark uses V58.49 more often. That's why it's important to look at each carrier's list of diagnosis codes indicating medical necessity for the post-op management.

Remember: If circumstances merit reporting modifier -59, you only use it on the day of the original procedure and the start of the post-op pain management. Do not report modifier -59 for subsequent days of care, Clark says.

Modifier refresher: Modifier -59's primary purpose is to let you report multiple procedures performed on the same day for different sites. These distinct services are each paid at full value instead of being subject to the multiple-procedure guidelines.

01996 Isn't Automatic for Other Days

When it's time to code for subsequent days of care, don't jump to conclusions - 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) might not be the correct code for the patient's management.

Begin by verifying whether the patient has patient-controlled analgesia (PCA) or patient-controlled epidural anesthesia (PCEA) before selecting a code for follow-up days. If it's a PCA, some coders say to report 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history, a problem-focused examination, medical decision-making that is straightforward or of low complexity).

Other coders recommend 62318 (Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or 62319 (... lumbar, sacral [caudal]) instead. If you report 62318 or 62319, these coders say you should append modifier -59 to distinguish the epidural's placement from the initial procedure.

If it's a PCEA (meaning the physician placed an epidural for pain relief), many coders report 01996 for each day of subsequent care.

Caution: The codes listed here (99231, 01996, 62318 and 62319) may not always be the best choices for PCA, depending on the carrier receiving your claim. Always check with the carrier in question before reporting PCA.

Remember: Normally, you do not bill any other services (including E/M) with 01996. The only exception is if the provider renders a separately identifiable service on the same day. In that case, most carriers direct you to report the appropriate procedure code with modifier -59 in addition to 01996 for the post-op pain management.

Exception: Double-check the policy before automatically appending modifier -59. For example, Clark's Medicare carrier requires modifier -AA (Anesthesia services performed personally by anesthesiologist) for subsequent days using 01996.

Negotiate Your Way to Payment

Carrier requirements and reimbursement for post-op pain management are all over the board. Clark says most of their carriers will pay (with the exception of Medicaid), but Howe says more of their carriers deny payment. That's why it's so important to check each carrier's policy before reporting the service so you'll be sure to follow their guidelines.

Carrier variation also means that post-op management is one issue you should discuss during contract negotiations. As many coders will agree, post-op pain control is a difficult issue to agree on, but the bottom line is that if the service is provided, the physician should be reimbursed.