Wiki Ileoinguinal Nerve resection for post op pain control

[TnRushFan]

Good afternoon everyone,

I was taught that anything done for post op pain control during a primary procedure was inherent to the primary procedure as it is included in the global post op period. One of my surgeons has been making his case that transecting the ilioinguinal nerve for post op pain control (specifically documented) is separately reportable...I disagree with him. Below I have included a short excerpt from one of his op notes as well as CMS instruction and a SuperCoder reference. I need to have a "slam dunk" professional opinion prior to our meeting on the subject.

Any thoughts are appreciated.

Op Note:
"At this point in time, the ilioinguinal nerve was identified and found to lay where it would be necessary to place our mesh. Therefore, we decided to completely excise the nerve in order to help prevent development of chronic postoperative inguinal pain (CPIP)."

CMS:
What services are included in the global surgery payment?
>
• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
• Post-surgical pain management by the surgeon
>

SuperCoder
You must also check to see whether the excision/transection is being performed for postoperative pain control. The Centers for Medicare and Medicaid Services has stated that the global surgical package includes postoperative pain management by the surgeon (see 100-04 Claims Processing Section 40).

Thanks to all...

 

[SharonCollachi]

If the patient is not a Medicare patient, then it may not be included, unless AMA or CPT Assistant says it is.

I think there may be confusion with the use of the phrase "postoperative pain management by the surgeon". This could mean something the surgeon does in the operating room to handle post-op pain that might come later, or it could mean actual pain management by the surgeon after the surgery, or both.

Here is more information on what Supercoder referenced: http://www2.aaos.org/bulletin/aug05/coding.asp

CPT Assistant appears to agree with your surgeon; however, this MIGHT ONLY be applicable to the anesthesiologist and not the surgeon:

2.1 CPT Assistant, Volume 7, Issue 2, February 1997 Anesthesia: Coding for Procedural Services “…An anesthesiologist could perform a therapeutic nerve block for pain management before or at the conclusion of the surgical procedure, or insert a catheter into the spinal column to induce continuous postoperative analgesia for therapeutic pain management. In the latter case, if an epidural catheter is inserted into the lumbar region, report code 62279*. This code includes insertion of the catheter and initial injection of the analgesic medication or fluid mixture that may then be connected to and controlled by an external infusion pump. Subsequent daily monitoring of the patient may be reported separately using an appropriate E/M code or anesthesia code 01996 because code 62279* does not include daily monitoring. Payor coverage and reporting requirements for daily monitoring services may vary.” *Note: CPT Code 62319 replaced 62279 in 2000.

And here:

2.2 CPT Assistant, Volume 8, Issue 7, July 1998 Coding Consultation “Question: How would you code a pain management service (64400-64530) in conjunction with an operative anesthesia service? The pain management injection (64400-64530) is not the operative anesthesia, but is administered pre, inter, or post- operatively for the purpose of postoperative pain management? “AMA Comment: It is appropriate to report a code from 64400-64530 in conjunction with an operative anesthesia service if an injection, as described by these codes, was also given. The February 1997 issue of CPT Assistant published an article on anesthesia and the coding of procedural services. Under ‘Reporting Additional Procedural Services’ it reads: “Additional procedural services provided in conjunction with basic anesthesia administration are separately reportable and coded according to standard CPT coding guidelines applicable to the REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH ANESTHESIA given code and the respective CPT section (eg, Surgery or Medicine sections) in which they are listed.”’Do not code procedural services with anesthesia coding guidelines.”

Here is the article: https://www.anesthesiallc.com/image...PROCEDURES IN CONJUNCTION WITH ANESTHESIA.pdf

 

[TnRushFan]

If the patient is not a Medicare patient, then it may not be included, unless AMA or CPT Assistant says it is.

I think there may be confusion with the use of the phrase "postoperative pain management by the surgeon". This could mean something the surgeon does in the operating room to handle post-op pain that might come later, or it could mean actual pain management by the surgeon after the surgery, or both.

Here is more information on what Supercoder referenced: http://www2.aaos.org/bulletin/aug05/coding.asp

CPT Assistant appears to agree with your surgeon; however, this MIGHT ONLY be applicable to the anesthesiologist and not the surgeon:

2.1 CPT Assistant, Volume 7, Issue 2, February 1997 Anesthesia: Coding for Procedural Services “…An anesthesiologist could perform a therapeutic nerve block for pain management before or at the conclusion of the surgical procedure, or insert a catheter into the spinal column to induce continuous postoperative analgesia for therapeutic pain management. In the latter case, if an epidural catheter is inserted into the lumbar region, report code 62279*. This code includes insertion of the catheter and initial injection of the analgesic medication or fluid mixture that may then be connected to and controlled by an external infusion pump. Subsequent daily monitoring of the patient may be reported separately using an appropriate E/M code or anesthesia code 01996 because code 62279* does not include daily monitoring. Payor coverage and reporting requirements for daily monitoring services may vary.” *Note: CPT Code 62319 replaced 62279 in 2000.

And here:

2.2 CPT Assistant, Volume 8, Issue 7, July 1998 Coding Consultation “Question: How would you code a pain management service (64400-64530) in conjunction with an operative anesthesia service? The pain management injection (64400-64530) is not the operative anesthesia, but is administered pre, inter, or post- operatively for the purpose of postoperative pain management? “AMA Comment: It is appropriate to report a code from 64400-64530 in conjunction with an operative anesthesia service if an injection, as described by these codes, was also given. The February 1997 issue of CPT Assistant published an article on anesthesia and the coding of procedural services. Under ‘Reporting Additional Procedural Services’ it reads: “Additional procedural services provided in conjunction with basic anesthesia administration are separately reportable and coded according to standard CPT coding guidelines applicable to the REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH ANESTHESIA given code and the respective CPT section (eg, Surgery or Medicine sections) in which they are listed.”’Do not code procedural services with anesthesia coding guidelines.”

Here is the article: https://www.anesthesiallc.com/images/eAlertsSource/REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH ANESTHESIA.pdf

Thank you so very much….we are having a meeting this week and I need as much information and references to back my position as possible. I also think you are right about them misrepresenting 'post op pain control'...if he just leaves off that statement and tells me a different reason why the nerve is being transected we can capture it.

 

[thomas7331]

I'm not sure I'd agree that this should not be coded. The NCCI guidelines, as I read them, are directed specifically at routine post-operative pain management in the global period. The excision of a nerve is not something that is routinely done, at least that I've seen. The procedure you are describing here is not directed at post-operative pain control, but is a separately identifiable intraoperative service that is documented as being required for prevention of chronic pain due to the location of the nerve in proximity to where the surgeon is going to place the mesh. This is not being done just to improve pain management during the 90-day global period, but is a treatment specific to this patient's condition.

In either case, though, if the CPT code for the nerve excision procedure is not bundled into the primary procedure in the NCCI tables, then it is a moot point because NCCI does not consider that service a component of the base procedure. The NCCI guidance is directed mainly at when the use of the modifier to unbundle a service may or may not be appropriate. I don't know what the primary procedure is in your example, but if the nerve excision procedure is not paired with that procedure in the NCCI table, then it can be reported.