General Surgery Coding Alert

Question: After undergoing a laparoscopic cholecys-tectomy, the patient returned to the office for a postoperative check, complaining of severe pain at the trocar site. The surgeon injected the patient with a peripheral nerve block. What diagnosis code should we use? Also, can we bill for the nerve block?

Arizona Subscriber

Answer: The nerve block is not payable separately by Medicare, which considers any type of postoperative pain management as included in the laparoscopic cholecys-tectomy's 90-day global period. The only exception for Medicare patients is if the patient must return to the operating room. In such cases, the appropriate pain management code should be reported with modifier -78 (Return to the operating room for a related procedure during the postoperative period).

Other payers may reimburse pain management services separately during the global period. Many Medicaid carriers, for example, do not assign global days to procedures, which means the nerve block could be reported.

The correct diagnosis code depends in part on where the trocar site is. Typically, there are four trocar sites: (1) main entry at the navel for the camera; (2) one at the right lateral subcostal margin; (3) the subzyphoid area; and (4) between the right lateral subcostal site and the subzyphoid site.

Depending on the patient's symptoms and the location of the trocar, the correct code could be 782.0 (Disturbance of skin sensation) if the problem relates to a nerve, 789.01 (Abdominal pain, right upper quadrant), 789.05 ( periumbilic), 789.06 ( epigastric), or 998.89 (Other specified complications of procedures) if the problem relates to the patient's stitches. The surgeon's written documentation is critical to determine what was performed, including distinguishing between a local anesthetic injection at the actual trocar site and a true nerve block.