Anesthesia Coding Alert

Tip: Always start with the surgeon’s request for services.

Every anesthesiologist provides pain management services from time to time, even if they don’t consider themselves to be pain management specialists. One prime example of this is postoperative care for patients following surgery. Read on for insights from Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida, on what to watch for the next time you’re faced with one of these claims.

Watch for Common Post-op Scenarios

The operating surgeon often handles the patient’s postoperative pain management but might request help from an anesthesiologist when a case is more complicated or requires more focused post-op care — such as after joint replacement surgery or other extensive orthopedic procedures.

Most pain management care provided by anesthesiologists fall into three categories:

• Femoral nerve blocks: 64447 (Injection(s), anesthetic agent(s) and/or steroid; femoral nerve) and 64448 (… femoral nerve, continuous infusion by catheter (including catheter placement))
• Interscalene blocks: 64415 (Injection(s), anesthetic agent(s) and/or steroid; brachial plexus)
• Lumbar epidurals: 62326 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance)

Tip: Finding one of these surgical claims on your desk should be a heads-up to double check for post-op care.

Important: 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 for either an injection or a continuous catheter.

Verify You Have Sufficient Documentation

According to National Correct Coding Initiative (NCCI) 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.”

That means you 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. Medicare also requires the surgeon to document in the patient’s medical record why referring the post-op management to the anesthesiologist is necessary.

From the anesthesiologist: The anesthesia records should clearly document that the post-op injection or catheter 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.

Keeping separate reports of surgical anesthesia and post-op care isn’t absolutely necessary, but might help the payer better understand the situation — which can speed up reimbursement.

The procedure note should be legible and include clear documentation of the following:

• That the surgical procedure is not dependent upon regional anesthetic technique
• The time spent on placement of the block or catheter
• The procedure

Plus: If your provider uses ultrasound guidance for the block or catheter, 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

Caveat: In most cases, Medicare considers injections routinely used for postoperative pain control to be bundled into the surgeon’s global services.

Brush Up on Payer Guidelines

It’s important to review payer guidelines for postoperative pain management since those 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).

Some payers, however, might allow you to report with one of the “X” modifiers if it better describes the situation than modifier 59. As many insurance companies now recognize the X modifiers, often the circumstances are better described using one of the following modifiers, as explained by Dennis:

• XP (Separate practitioners…): For example, if Dr. X provided anesthesia and Dr. Y provided post-op pain management, the XP modifier best describes the situation.
• XU (Unusual non-overlapping service…): If NCCI allows separate reporting as long as the requirements listed above are met, this modifier may be preferred by the insurer.
• XE (Separate encounter…): If the post-op pain injection or catheter is documented as either before or after reported anesthesia time, it may be considered a separate encounter.

“The XS (Separate structure…) modifier does not usually apply as the injection or catheter is typically given in the same anatomical structure as the surgery is performed,” Dennis notes.

Tip: You may need to work with your insurance carriers to determine which modifier they prefer. NCCI updated their parenthetical information in 2020 to add modifiers XU and XE as applicable modifiers to bypass the bundling edits.

Decide on the 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. These options could include:

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