Anesthesia Coding Alert

Tip: Pay particular attention to every bit of documentation.

Even if your anesthesiologists don’t consider themselves pain management specialists, they’ll still sometimes provide pain management services. These will most often come in the form of postoperative pain management for patients after surgery. We checked in with some longtime anesthesia coding experts to get their top advice for filing these claims.

Tip 1: Keep an Eye Out for Certain Situations

In most cases, the operating surgeon handles the patient’s postoperative pain management for two reasons: It’s not usually very complicated and it’s included in the surgical fee. The surgeon might request help from an anesthesiologist, however, for cases that are more complicated or that require more focused post-op care.

“We do see a lot of post-op pain management,” says Cindy Hinton, CPC, CCP, CPCO, of Advanced Coding Solutions, LLC, in Franklin, Tenn. She cites three types of pain management care that they see most often:

• Femoral nerve blocks – 64447 (Injection, anesthetic agent; femoral nerve, single) and 64448 (… femoral nerve, continuous infusion by catheter [including catheter placement])
• Interscalene blocks – 64415 (Injection, anesthetic agent; brachial plexus, single)
• Lumbar epidurals – 62319 (Injection[s], including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral [caudal]).

“Many of these are provided following joint replacement surgeries as well as other extensive orthopedic procedures,” Hinton says.

What it means: When your provider administers anesthesia during an extensive surgery such as joint replacement, don’t be surprised to find additional services for post-op pain management. Finding one of these surgical claims on your desk should be a heads-up to double check for post-op care.

Tip 2: Verify You Have Documentation From Both Providers

According to the Correct Coding Initiative’s (CCI’s) guidance, routine post-op pain management care cannot be reported by an anesthesiologist or pain management specialist “unless separate, medically necessary services are required that cannot be rendered by the surgeon.”

Because of this stance, you’ll need documentation from both sides of the care before your anesthesiologist can charge for the service.

From the surgeon: The surgeon should request in writing that the anesthesiologist provide post-op pain management care for the patient. It should be clear that the post-op care will be separate from any anesthesia administered during the surgery.

From the anesthesiologist: The anesthesia records should clearly document that the post-op injection is separate from surgical anesthesia – including separate procedure notes. Your provider’s notes should include details regarding the service performed, the substance injected, the site of injection, and the substance dosage.

Traditionally, anesthesia providers have documented the surgeon’s request for post-op pain management, either on the anesthesia record or a separate block form. This isn’t always the best tactic, however.

“The problem with this is that auditors are not seeing corresponding documentation from the surgeon, such as orders for the pain block or catheter,” says Kelly D. Dennis, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. “As there have been some cases of insurance companies recouping payment when the documentation did not support the surgeon’s request, it would be a good idea to make sure the surgeon is also documenting the need for postoperative pain management by the anesthesia provider.”

The procedure note should be legible and should include the following:

• Clear documentation that the surgical procedure is not dependent upon regional anesthetic technique
• Clear documentation of the time spent on placement of the block or catheter
• Clear documentation of the procedure.

Plus: If your provider uses ultrasound guidance for the block or catheter, Dennis says you should also have procedure notes that are in line with the code description in CPT^®:

• Evaluation of the potential access site
• Documentation of selected vessel patency
• Concurrent real-time ultrasound visualization of vascular needle entry
• Permanent recording and reporting.

Tip 3: Review Your Payers’ Guidelines

“It’s very important to review payer guidelines for postoperative pain management,” Hinton says. “Those will often include documentation guidelines.”

Example: Know whether the insurer expects you to append modifiers to the post-op injections to help separate it from the surgical anesthesia. In most cases, this would be modifier 59 (Distinct procedural service). “We’re finding that almost all payers still require the 59 for these procedures,” says Hinton.

Some payers, however, might allow you to report with one of the “X” modifiers.

“I’ve seen some coders reporting the X modifiers,” Dennis says. “They can be used if the X modifier is more descriptive than the 59 (which CCI edits still shows as the correct modifier) and the insurance company will accept the X.”

Tip 4: Dig Into Your Best Diagnoses

You’ll also need clear documentation of the patient’s diagnosis supporting your provider’s service.

Example: The surgeon requests post-op pain management care for a patient following shoulder surgery. If the surgeon doesn’t document a specific diagnosis, you should code based on the patient’s signs and/or symptoms. In the case of shoulder surgery, you could possibly report one of three choices, depending on the circumstances:

• M25.511 – Pain in right shoulder
• M25.512 – Pain in left shoulder
• M25.519 – Pain in unspecified shoulder.

Final point: As this is not “routine postoperative pain” handled by the surgeon, you might also need to report a code from the G89 section. Dennis says these options could include:

• G89.11 – Acute pain due to trauma
• G89.12 – Acute post-thoracotomy pain 
• G89.18 – Other acute postprocedural pain.