Anesthesia Coding Alert

Question: My pain management specialist inserted a catheter for a continuous femoral nerve block for acute postoperative pain management for a patient who had an open reduction internal  fixation (ORIF) for a distal femur fracture. His notes indicate he checked in on the patient for two days to manage the continuous infusion. Can I separately report the catheter insertion?

New Jersey Subscriber

Answer: You can bill for the insertion of continuous femoral infusion catheter separately, as long as your provider did not use it as part of the anesthesia for the ORIF.

Here's how: If your specialist placed the catheter for postoperative pain management, you would report 64448 (Injection, anesthetic agent; femoral nerve, continuous infusion by catheter [including catheter placement]).

The Correct Coding Initiative (CCI) edits bundle 64448 as a column 2 code into the majority of the anesthesia services codes, including 01360 (Anesthesia for all open procedures on lower one-third of femur). This bundling edit can be bypassed with a modifier, such as modifier 59 (Separate and distinct procedure), if the documentation supports that the catheter placement was indeed separate and distinct from the anesthesia services performed on the same date of service.

Important: Since post-operative pain management is included in the global surgical fee schedule, payers place a lot of importance on the fact that the surgeon requested the service. You should ensure that you include documentation of this request when you bill. For the medically necessary post-op visits your pain management specialist performed on the following two days, you should code the E/M service from the subsequent hospital care CPT category, 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs.) Check your provider's documentation to determine the appropriate level of service.

Post-operative pain management services provided by the anesthesiologist are starting to be an area of scrutiny for payers -- they're especially focusing on the medical necessity of post-operative visits and the level of service billed. Remember that the base units for the anesthesia service include the "usual postoperative anesthesia visit" and would not be separately billable. Documentation is the key to supporting the medical necessity of any provider services.