Eli's Rehab Report

Although you should choose 01995 when administering Bier blocks for surgical anesthesia, some payers do not allow this code for pain management-related Bier block procedures. Instead, report 90784 or the code for unlisted nervous system procedure (64999) for these services.

When patients require Bier blocks, the physiatrist applies a tourniquet to the patient's extremity to create targeted anesthesia delivery. "Because they use tourniquets, physicians typically use Bier blocks for procedures that last less than an hour," says Cindy Clark, coding supervisor with the physician group Anesthesiology Consultants in Savannah, Ga. "That's so the blood supply isn't cut off too long and the tourniquet pain does not get too severe."

Physiatrists often administer Bier blocks to patients with reflex sympathetic dystrophy (RSD, 337.2x). Because the physiatrist uses the block to treat a chronic pain syndrome and not as a surgical anesthetic, coders differ regarding which code is most appropriate.

"Although 01995 (Regional intravenous administration of local anesthetic agent or other medication [upper or lower extremity]) is the most appropriate code for the Bier block, a note following its descriptor in CPT advises coders to refer to 90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous) for intravenous or intra-arterial pain management therapy," says Trish Bukauskas, CMM, CPC, owner of TB Consulting in Myrtle Beach, S.C. "The IV that 90784 describes, however, involves a slow infusion, whereas during a Bier block the physician applies a cuff to the extremity to keep all the blood where the pain is, then he administers an anesthetic, steroid and other medications into that spot. So 90784 doesn't really describe it accurately."

In addition, Medicare bundles reimbursement for 90784 into all other services performed on the same day, so unless the Bier block is the only service the physician performs, Medicare will deny claims for 90784.

Some carriers, such as Blue Cross and Blue Shield of Oregon, advise practices to report regional nerve block codes (64400-64530) for Bier blocks. But none of the nerve block codes describe Bier blocks appropriately, Bukauskas says. "Some practices report 64450* (Injection, anesthetic agent; other peripheral nerve or branch), but Bier blocks aren't administered in peripheral nerves, so this code isn't accurate."

This leaves the unlisted-procedure code (64999) as your only choice if your carrier disallows 01995 for pain management procedures. If you report 64999 for Bier blocks, always send your operative notes with the claim. To set your fee, compare reimbursement to 01995 (usually between $80 and $100), and ask the physician to write the carrier a short letter explaining the similarities between the Bier block and the services described in 01995.

Some carriers, such as Florida Medicare, list Bier blocks with bretylium as a noncovered service, although most carriers do not publish policies regarding Bier blocks with other drugs, such as lidocaine. You should contact your carrier before administering a Bier block to determine whether it is a covered service.