Anesthesia Coding Alert

The one thing you always need to establish is medical necessity -- and a post-op femoral block procedure is no exception. Our experts give you the scoop on what you need to know when you consider billing for post-op visits.

Consider this example: Your pain management specialist inserts a catheter for a continuous femoral block for acute post-op pain management for a patient on long-term opioids who had an open reduction internal fixation (ORIF) for a distal femur fracture. Then your physician tells you that he did post-op "rounds" on the patient for two days to monitor the continuous infusion.

"Assuming the services are provided by the anesthesiologist, all of the experts are in agreement that as long as the continuous infusion is not used as the mode of anesthesia for the surgery, the pain management procedure should be separately billable," says Pamela Linton, CPC, anesthesiology coding specialist with Medical Management Professionals, in Chattanooga, Tenn.-

"If the catheter for the femoral block was inserted at the time of surgery, we would bill it out as 64448 (Injection, anesthetic agent; femoral nerve, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) using modifier 59 (Distinct procedural service) with diagnosis code 338.18 (Other acute postoperative pain)," says Kelly Dennis, MBA, CPC, ACS-AP, with Perfect Office Solutions of Leesburg, Fla. You can find more information on category 338 at http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm.

Code 338.18 tip: The ICD-9 guidelines specifically state that acute postoperative pain diagnosis codes cannot be reported for routine or expected postoperative pain immediately after surgery. In this scenario, the patient potentially won't have the routine or expected pain levels because of potential narcotic tolerance due to long-term use for another condition.

"There is a 10-day global period associated with 64448," Dennis says. That means "no other related services should be billed in that time frame when a continuous femoral infusion is used for post-op pain management," she says.

According to CPT: The code descriptor for 64448 includes "daily management for anesthetic agent administration." You only charge for the initial continuous infusion service -- the 64448 charge includes any subsequent E/M services directly related to the original procedure.

Lesson: You should not report routine post-op visits for 64448 separately.

Reminder: All the continuous infusion codes in the 64405-64450 range have 10-day global periods. These include 64448, 64416 (... brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration), 64446 (... sciatic nerve, continuous infusion by catheter [including catheter placement], including daily management for anesthetic agent administration) and 64449 (... lumbar plexus, posterior approach, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration).

Any follow-up visits, including subsequent hospital care, performed in that 10-day period are included in the relative value units for the procedure. These procedures have a much higher value than their single-injection counterparts, Linton says.

Notable exception: The global period specified for 64447 (... femoral nerve, single) is zero, which means the procedure has no postoperative global days associated with it. This is because a 64447 service typically doesn't require multiple follow-up visits.

But when the patient's condition requires a subsequent E/M visit by your acute pain management provider, you can potentially bill for the service. When you do have the chance to bill inpatient subsequent care (99231-99233), here's what you need to watch out for.

Problem: "There are a couple of issues in dealing with post-op pain management in general," Linton says.-"The first stems from a lack of documentation from the provider to show that this service is requested by the surgeon and the reason that the surgeon cannot provide the postoperative pain management services."

Solution: You have to firmly establish medical necessity for the procedure. If you don't, the payer could -- and has -- come back in post-payment reviews, Linton says. In a worst-case scenario, this could lead to a payer requesting money back.

Better not forget: CMS says that the best way to determine the appropriate level of any service is medical necessity. According to Medicare Carriers Manual, Part 3, Chapter XV, section 15501.A, "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code ... The volume of documentation should not be the primary influence upon which a specific level of service is billed.-Documentation should support the level of service reported."-

The physician's documentation will be critical in meeting these standards.-Sometimes a patient's pre-operative conditions, such as narcotic-dependence history, will require the assistance from an acute pain management provider. Or perhaps the provider injects a specific medication with higher risk of adverse side effects for postoperative pain control.-When the provider documents this type of detail, he can establish medical necessity, and you can bill for a subsequent visit. However, when a patient has a routine procedure and doesn't have any other pre-existing conditions, the provider should be very careful billing for the visit, Linton says.