Anesthesia Coding Alert

Check these 3 areas to be sure you're up to speed

If your physicians routinely provide short-term pain management services, don't shortchange your claims by reporting incorrectly. Verifying a few simple details can make a difference in the code you submit -- and your group's bottom line.

Clue in to Terminology  

Acute pain management treats short-term pain, often following the patient's surgery. Physicians can administer epidurals, spinals or blocks, depending on the situation. When you code your claims, watch for some key words in your provider's documentation -- they can help you code correctly and possibly bump up the base units you report.
 
Keep these terms in mind as you code:
 
• Continuous versus single: Sometimes your physician simply administers a single-shot injection to relieve the patient's pain; sometimes he needs to do more. Knowing the type of injection -- and having supporting documentation -- could mean a difference of four or five base units.
 
Example: Your physician administers an interscalene block following shoulder surgery. If he administers a single injection, report 64415 (Injection, anesthetic agent; brachial plexus, single) at eight base units. If he inserts a catheter for continuous infusion, however, report 64416 (... brachial plexus, continuous infusion by catheter including daily management for anesthetic agent administration) at 13 base units instead.
 
• Prone position: Surgical positioning makes a difference in reimbursement, Hal Nelson, CPC, vice president of anesthesia with CompONE Ltd. recently told attendees at the University of Chicago's Anesthesia Billing and Management Conference in Las Vegas.
 
If one of your physicians provides anesthesia while another physician administers a nerve block, be sure to check the patient's position. Code the anesthesia service with either 01991 (Anesthesia for diagnostic or therapeutic nerve blocks and injections; other than the prone position) or 01992 (... prone position).
 
Being able to report the prone position means five base units instead of three. Then code the second physician's pain management service accordingly, such as with the appropriate nerve block choice from 64400-64484 (Injection, anesthetic agent ...).

Note: Physicians do not administer many of these nerve blocks while the patient is in the prone position, says Scott Groudine, MD, an anesthesiologist in Albany, N.Y. Watch for notes regarding prone position with sciatic nerve blocks (64445, ... sciatic nerve, single; and 64446, ... sciatic nerve, continuous infusion by catheter, [including catheter placement] including daily management for anesthetic agent administration), lumbar plexus blocks (64449, ... lumbar plexus, posterior approach, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) and 64450 (... other peripheral nerve or branch). 

Follow Medical Direction Guidelines     

You need to be especially careful when coding services that your anesthesiologists report as medically directed. These guidelines -- known as the seven rules of medical direction -- outline a medically directing physician's responsibilities. Some of these guidelines are cut-and-dry, but others leave room for interpretation. (See "Check Med Direction Guidelines for Post-Op Block" in Reader Questions on page 54 for the list of guidelines.) 
 
Some states, such as Georgia and Pennsylvania, set additional guidelines for the types of services your physicians can conduct while medically directing. These allow physicians to check on laboring patients, provide administrative tasks and complete other basic services without breaking medical direction.
 
The question for some groups is, "Can our physicians provide pain management services while medically directing cases?"
 
The answer is "Yes -- in certain circumstances."
 
"While medically directing, you can administer a block for a patient waiting for surgery, or a recovery room patient who has just had surgery -- if your carriers say it's OK," Groudine says. "These services are not OK in New York or some other states yet."
 
Warning: Even if your carrier allows for additional services as part of its medical-direction guidelines, don't bend the rules to include other cases. "It is always wrong to move a pain practice to the operating room or post-anesthesia care unit to do blocks on patients who have not had surgery that day," Groudine says.

Get Documentation -- From Both Sides

When you submit a claim for acute pain services, having your physician's record of services isn't enough. You also need a documented transfer of care from the surgeon, according to National Correct Coding Initiative (NCCI) guidelines.
 
Carriers' reimbursement for CPT surgical codes incorporates postsurgical care -- and that includes pain management. If the surgeon believes his standard IV patient-controlled analgesia won't be enough, he'll arrange for a pain management specialist or anesthesiologist to handle postoperative pain management instead.
 
The surgeon should document in his record that he'll hand off postoperative pain management to the anesthesiologist. Your physician's record should include documentation of this transfer such as, "Post-op pain management to be provided per surgeon's request" or "after discussion with surgeon."
 
You'll report the initial day of pain management care with the code appropriate to the service (spinal block, interscalene block, continuous or single-shot injection, etc.). Append modifier 59 (Distinct procedural service) to indicate that the pain management catheter or injection is separate from the original procedure.
 
Follow up: If your physician provides additional days of care, you have two coding options:
 
• Report 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) for epidural or spinal catheter management
 
• Report the appropriate E/M code for cases that don't include a catheter. 

Some carriers limit how many days you can bill for postoperative pain management, but others don't. Most carriers approve the service for one to three days after the surgery (not including the catheter insertion). Check your carrier's guidelines to ensure you correctly report follow-up management.