Anesthesia Coding Alert

These 3 tips will keep your claims on track every time.

When you see documentation of “post-op brachial plexus block,” don’t assume that the catheter placement is included in your anesthesiologist’s service during surgery. Your practice can earn approximately $78 in a facility setting (based on the national Medicare conversion factor of $34.023) each time you’re justified in reporting the post-op block separately.

Remember these three tips to know when you can (or can’t) add 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) to the claim.

Tip 1: Watch for 64416 Post-Op Opportunities

Patients often need postoperative pain management, especially after extensive surgeries. If the surgeon isn’t comfortable handling the pain management, he may request that the anesthesiologist oversee that part of the patient’s care. Any type of shoulder repair surgery – rotator cuff, partial rotator cuff, total replacement – is one of the more common uses of nerve blocks for post-op pain relief. The need applies to either open or arthroscopic shoulder procedures, says Leslie Johnson, CCS-P, CPC, manager of coding, compliance and education for Somnia, Inc., in New Rochelle, N.Y.

When the surgeon asks for postoperative pain management after shoulder surgery, the anesthesiologist will administer a brachial plexus block to temporarily stop nerve sensations and movement in the upper extremity.

Justify it: The Correct Coding Initiative guidelines indicate that routine postoperative pain management services are included in the global surgical fee and “shall not be reported by the anesthesiologist unless separate, medically necessary services are required that cannot be rendered by the surgeon.” An axillary (brachial plexus) block, which a surgeon does not have the expertise or training to do, would be a separate reimbursable service.

Example: An orthopedic surgeon performs a total shoulder replacement. Before the operation, the surgeon requests that your anesthesiologist administer a brachial plexus block via a continuous catheter (64416) for postoperative pain management. Your anesthesiologist places the catheter and the patient receives a general anesthetic for the repair of the shoulder. The catheter remains in place to allow the patient to wake up pain free. You can report 64416 in addition to the applicable anesthesia code for the actual surgery (01638, Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; total shoulder replacement).

Beware: A payer would likely reject codes for starting patient-controlled anesthesia (PCA), however, since that service could be rendered by the surgeon.

Takeaway: Always check for notes regarding a brachial plexus block or postoperative pain management services when you code for shoulder surgery.

Tip 2: Remember to Add Modifier 59

Many payers require that you append modifier 59 (Distinct procedural service) to 64416 unless specific payer policy disallows use of the 59 modifier with a single line item claim.

“They also want you to append modifier 59 when reporting 64415 (Injection, anesthetic agent; brachial plexus, single),” Johnson says. “Otherwise, the payer will bundle these codes with the main mode of anesthesia during surgery instead of recognizing it as a separate procedure.”

Don’t miss: Code 64416 no longer has a 10-day global period, according to CMS. That means that if your anesthesiologist completes a follow-up check you can charge an E/M service such as 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient...) for maintaining the catheter.

Tip 3: Get Request and Details in Writing

You can only report 64416 separately if you have documentation from the anesthesiologist supporting the separate nature of the catheter.

For instance, in the above example, the surgeon who requested postoperative pain management after the patient’s shoulder replacement should do so in writing. This indicates that the catheter procedure was separate from the surgical procedure and gives the anesthesiologist documentation to support the billing.

When placing the brachial plexus block, the anesthesiologist should document the procedure performed, the catheter site, substance injected, and the dosage of the substance. The patient’s chart should also include the time of catheter placement (64416) or block injection (64415).

Pointer: Coders often recommend including an area on the anesthesia record for documenting these items, such as separate boxes for the digital start and stop times of the injection or block. Some payers may require this information to prove that the minutes were not included in the anesthesia time.

“Also be very careful of the new CCI regulations where pain management codes might be bundled with the main mode of anesthesia,” Johnson warns. “For example, you can’t bill the pain management portion if the main mode of anesthesia during surgery is MAC or a regional block. We need to be more careful in how we code for post-op pain blocks in general.”

Final tip: In addition to the requirements discussed above, ensure that your providers document the patient’s diagnosis (such as the reason for shoulder surgery) to support billing for the postoperative care, says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. “Coders often presume the block is for post-op pain management,” she notes. “And that’s not really allowed unless the anesthesiologist has documentation to support his role.”