Anesthesia Coding Alert

Documentation of your provider’s role is crucial.

Surgeons normally provide postoperative pain management themselves, but sometimes they request help from an anesthesiologist because of particular circumstances. This is especially true for procedures such as arthroscopic shoulder surgery because the post-op management is more involved than the surgeon normally handles. Read on for four key points to watch before submitting a separate claim for the post-op injection or catheter placement. 

1. The injection or catheter placement must be administered by a different physician 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 request post-anesthesia pain management in an attestation on the record,” says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. 

2. Your 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 physician 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. 

3. 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. 

4. 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. 

MAC note: Medicare does not allow separate billing of a post-op epidural or peripheral nerve block administered either preoperatively or intraoperatively if the anesthesia provider used MAC (monitored anesthesia care), moderate conscious sedation, or regional anesthesia by peripheral nerve block during the surgery. 

“The ‘pain block’ would end up being part of the anesthetic used for the surgery,” Dennis explains. “When MAC or regional is listed on the anesthesia record, most coders know to ask about the circumstances.” 

If you do report the epidural or peripheral nerve block injection for post-op pain management on the same day as an anesthesia code for surgery, append modifier 59 (Distinct procedural service) to indicate the post-op block was separate from surgical anesthesia.

Choose the Right Codes

Once you know separate post-op billing is justified, be sure to submit the correct code based on the surgical site and the type of block administered. 

Shoulder surgery: Report 64415 (Injection, anesthetic agent; brachial plexus, single) for a single injection or 64416 (… brachial plexus, continuous infusion by catheter [including catheter placement]) for infusion using a continuous infusion pump for post-op pain relief. Remember that an interscalene block is a block of the brachial plexus. Because of this, you should also submit 64415 for a single-shot interscalene block.  

Knee surgery: Submit 64447 (Injection, anesthetic agent; femoral nerve, single) for a single femoral nerve injection or 64448 (…femoral nerve, continuous infusion by catheter [including catheter placement]) for a femoral block using a continuous infusion pump. 

Ankle or foot surgery: CPT® does not include a code specific for nerve blocks to the ankle or foot area (such as for the sural nerve). Because of this, your best choice for a pain management injection in these cases is 64450 (Injection, anesthetic agent; other peripheral nerve or branch). 

Other options: The 644xx codes represent single injections of pain medication, which are common for arthroscopic joint procedures. If your physician uses an epidural catheter for post-op relief, you’ll focus on a different set of codes: 

• 62310 – Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic
  
• 62311 – … lumbar or sacral (caudal)
  
• 62318 – 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; cervical or thoracic
  
• 62319 – … lumbar or sacral (caudal).