Anesthesia Coding Alert

Clear documentation of each phase should help your reimbursement chances.

When your anesthesia provider is asked to handle a patient’s postoperative pain management, you want to be sure all the supporting documentation is in order. Cindy Hinton, CPC, CCP, CPCO, of Advanced Coding Solutions, LLC, in Franklin, Tenn., shared some advice for these situations in our last issue (see “Follow This Advice for Successful Post-op Pain Management Claims” in ACA Vol 18, N. 8). Now, here are four more points to watch before submitting a separate claim for the post-op injection or catheter placement.

• The injection or catheter placement must be administered by a different physician (i.e, your anesthesia provider) than the surgeon who performed the surgery. Medicare requires the surgeon to document in the patient’s medical record why referring the post-op management to the anesthesiologist is necessary. “Typically, there’s documentation to indicate the surgeon requested post-anesthesia pain management in an attestation on the record,” says Kelly Dennis, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.
• Your anesthesia provider should complete a separate procedure report for the post-op pain management procedure. It should not be part of the surgeon’s operative report, and preferably not part of the anesthesia record if the same anesthesia provider handled both aspects of the patient’s pain relief (anesthesia during surgery and postoperative management). Keeping separate reports isn’t absolutely necessary, but might help the payer better understand the situation – which can speed up reimbursement.
• The block used for post-op pain management cannot be an extension of the anesthesia used during surgery. You need documentation of the start and stop times for surgical anesthesia and separate documentation of the post-op block’s placement. Because of this, you’ll also need to report separate codes for anesthesia and post-op pain management – the appropriate 0XXXX code for anesthesia during surgery and the applicable pain management code.  
• In most cases, Medicare considers injections routinely used for postoperative pain control to be bundled into the surgeon’s global services. If you aren’t able to file separately from the surgeon, you’ll need to make an agreement with the surgeon regarding how to get your provider’s payment from the surgeon’s reimbursement.