Anesthesia Coding Alert

A surgeon’s note requesting POPM could mean the difference between getting paid and not getting paid!

If a surgeon places your provider in charge of a patient’s postoperative pain management (POPM), opportunity knocks, but danger lurks.

Rightful reimbursement is possible, but you’ll want to be careful not to make any missteps, or you could be looking at a rejected claim. Avoid such a fate by heeding this expert advice.

Know Why Another Physician May Provide POPM

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

“Anesthesia providers are trained in specialty blocks that surgeons are not trained to provide. These blocks and/or catheters allow patients to recover more quickly, saving money in the long run,” says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. “Savings result from patients having quicker recovery time, which means less time in the facility, and they require less medication to treat pain,” she adds.

“Management of postoperative pain has proven itself to improve patient outcomes,” notes Amy Turner, RN, BSN, MMHC, CPC, CHC, CHIAP, managing director at Ankura in Nashville, Tennessee. “Patients are more willingly mobile and successful in participating in physical therapy as well as coughing and taking deeper breaths. Fewer complications, such as pneumonia and blood clots, are noted in patients who are active during their postoperative period. Length of hospital stay may also be reduced, and these modalities lead to decreased need for opiate medications, which we all know is optimal given the opioid crisis we currently face,” she explains.

Recognize Proper Reporting for Routinely Performed POPM Services

Base your POPM procedural coding on the nerve targeted and whether the pain management (PM) specialist performed a block or placed a catheter for continuous infusion.

Often, post-op pain control for total knee procedures includes both femoral and sciatic nerve blocks/catheters to relieve pain in the front and back of the knee. Code choice is based on technique and the nerves targeted:

1. 64445 (Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, including imaging guidance …)
2. 64446 (… sciatic nerve, continuous infusion by catheter (including catheter placement), including imaging guidance …)
3. 64447 (Injection(s), anesthetic agent(s) and/or steroid; femoral nerve …)
4. 64448 (… femoral nerve, continuous infusion by catheter …)

Keep in mind: A “popliteal block” procedure note without a description of the anatomy is not helpful to coders when determining the correct code to report. If that’s the only information documented, ask your provider if they mean “sciatic” rather than “popliteal.” If so, report the injection with 64445, Dennis advises.

Paravertebral blocks, also called paraspinous blocks, help control post-op pain in the thoracic area and are coded with 64461 (Paravertebral block (PVB) (paraspinous block), thoracic; single injection site …) through 64463 (… continuous infusion by catheter …).

Interscalene blocks target the group of nerves that run from the base of the neck to the arms to provide pain relief and are coded with 64415 (Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance …) and 64416 (… continuous infusion by catheter …).

Don’t miss: Except for transversus abdominis plane (TAP) blocks, planar blocks do not target a specific nerve and are reported with an unlisted code, 64999 (Unlisted procedure, nervous system), according to the December 2022 CPT^® Assistant.

“When reporting an unlisted code, make sure you send in the required documentation: this includes the surgeon’s request, a procedure note that fully describes the block or catheter, and a comparable code for payment purposes. Take heart, though — new codes for planar blocks should be ready by 2025!” Dennis says.

Pro tip: Always check the documentation carefully and ensure you understand the procedure being performed. For example, several terms are used to describe a “brachial plexus” block, such as “interscalene,” “infraclavicular,” or “supraclavicular.” Do not confuse these with codes with a similar-sounding description (i.e., “suprascapular”).

Once you’ve selected the appropriate CPT^® code for the POPM, be sure to append the appropriate X{EPSU} modifier or -59 (Distinct procedural service), depending on payer preference, to signify the service was distinct from the anesthesia provided for the surgery.

Be Sure Both Providers Document Service Particulars

Traditionally, anesthesia providers have documented the surgeon’s request for POPM in the record or on a separate block form. However, this isn’t always the best tactic.

“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 Dennis. “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 POPM.”

Plus, according to National Correct Coding Initiative (NCCI) guidance, a pain specialist cannot report post-op pain management care “unless separate, medically necessary services are required that cannot be rendered by the surgeon.”

Bottom line: You’ll need documentation from both sides of the care team before your provider can charge for the POPM service.

From the surgeon: The surgeon should make a written request and document in the patient’s medical record why referring the post-op pain management to your provider is necessary.

From the PM specialist: Your provider’s notes should detail the service performed. The procedure note should be legible and include clear documentation of the following:

• The PM procedure, substance injected, dosage, and nerve targeted.
• Time spent on the block or catheter placement.
• The surgical procedure was not dependent upon the efficacy of the regional anesthetic technique.

If the physician uses ultrasound guidance for the block/catheter (even if NCCI bundles the procedure and imaging), Dennis says the procedure note should also include:

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

Document Diagnosis Clearly With These ICD-10-CM Codes

You’ll also need clear documentation of the patient’s diagnosis supporting your provider’s POPM service. When in doubt, either a G code or an M code will do the trick.

Example: The surgeon requests POPM for a patient following left shoulder surgery. If the surgeon doesn’t document a specific diagnosis, you should code based on the patient’s signs and/or symptoms such as M25.512 (Pain in left shoulder).

As this is not “routine postoperative pain” handled by the surgeon, you might 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), or G89.18 (Other acute postprocedural pain).

Pro tip: Keep your eye on denials. If the diagnosis code or a lack of documentation is causing denials or recoupments, check for payer guidelines regarding POPM reporting.