When it comes to getting paid for post-oppain blocks, not all payors require thesame documentation and proof of medical

necessity. Some commercial carriers follow theMedicare edits and guidelines while others don’t fol-low Medicare reimbursement — potentially allow-ing for more aggressive coding and reporting. Here’sa review of different post-op pain directives.

• American Medical Association. The AMAsays it’s appropriate to report pain managementprocedures for post-op analgesia separately fromthe administration of a general anesthetic. “Whetherthe block procedure (insertion of catheter; injectionof narcotic or local anesthetic agent) occurs pre-operatively, post-operatively or during the proce-dure is immaterial,” reads AMA CPT OCT 01; 9. TheAMA lists 2 exceptions, however. One, if the blockprocedure is used primarily for the anesthesia itself,report the service using the anesthesia code alone.Two, don’t report the block separately in a com-bined epidural/general anesthetic. Keep in mind thateven though the AMA allows for separate reportingunder specific circumstances, commercial carriersmight have varying reporting and billing policies. Besure to verify them.

• Centers for Medicare & Medicaid Services.

CMS says there’s no separate payment for post-oppain management when provided by the physicianperforming an operative procedure, noting on page6 of the CMS Chapter 2 NCCI Manual that surgeonswho provide post-op pain management are reim-bursed under a global payment policy related to theprocedure. CMS further states that anesthesia prac-titioners shall not report post-op pain proceduresunless “separate, medically necessary services arerequired that cannot be rendered by the surgeon.”In such cases, CMS says “the surgeon is responsibleto document in the medical record the reason careis being referred to the anesthesia practitioner.”

Surgeons may report CPT codes 36000, 36410,37202, 62318-62319, 64415-64417, 64450, 64470,64475, and 90760-90775 “only if provided for purpos-es unrelated to the [post-op] pain management, theoperative procedure or anesthesia for the proce-dure,” according to Medicare Global Surgery Rules.

• Local coverage determination policies. LCDpolicies provide documentation and medical neces-sity essentials for specific procedures. Your MAC/FImay offer LCD policies that provide more specificcoding directives for many procedures, includingcertain pain injections and blocks. Many statesdon’t have a specific LCD policy for the more com-

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R E I M B U R S E M E N T

Deciphering different post-op pain directives is key to getting theproper reimbursement. Cristina Bentin, CCS-P, CPC-H, CMA | Baton Rouge, La.

How to Report Post-op Pain Blocks

POST-OP ANALGESIA Somecarriers let you separately report post-op pain blocks.

mon post-op pain block proce-dures due to the CMS NCCIManual directive that is already inplace. For those states with LCDpolicies for pain blocks for post-op pain, review the policy — inits entirety (see “Read LCDs inTheir Entirety”).

Documenting blocksWhile most pain managementproviders are usually on targetwhen describing injection proce-dures, the ball gets dropped toooften when it comes to document-ing post-op pain blocks. Detaileddocumentation is essential and thepost-op pain injection must beseparate and distinct from theanesthesia used to perform thesurgery. Many commercial carriersthat allow separate reportingadvise a separate operative reportor procedure note for the injec-tion. Likewise, many commercialcarriers have medical necessityand provider requirements.

We found these examples ofgrossly deficient post-op painblock dictation within operativereports that provided no separateoperative reports for the block:

• “The patient was given ablock followed by endotrachealanesthesia.”

• “Anesthesia: General endo-tracheal anesthesia with block.”

• “A scalene block was givenfor post-op pain control.”

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Read LCDs in Their EntiretyIt’s easy to misinterpret local coverage determination policies for peripheral nerveblocks if you make it through the medically necessary conditions but omit the remain-ing contents of the LCD containing the documentation requirements. Take, for exam-ple, the following excerpt from First Coast Service Options’ LCD:

“Medicare will consider peripheral nerve blocks medically reasonable and neces-sary for conditions such as the following diagnostic and therapeutic purposes:

When a single injection peripheral nerve block provides post-surgical pain control1. during the transition to oral analgesics2. in those procedures that cause severe pain normally uncontrolled by oral analgesics3. in cases otherwise requiring control with intravenous or parenteral narcotics.4. in cases where the patient cannot tolerate treatment with narcotics due to allergy or

side effects, etc.”If you read only the excerpt above and not the LCD in its entirety, you’ll miss the

remainder of the LCD that reads:“Based on Medicare rules, regulations and Correct Coding Initiative (CCI) edits,

nerve blocks are not separately payable when done by the surgeon or the anesthesiaprofessional who provides anesthesia/analgesia for the procedure. When preemptiveanalgesia is performed by a provider other than the surgeon or the anesthesia profes-sional who provides anesthesia/analgesia for the procedure, there must be a com-pelling patient care reason for the involvement of the additional provider. The rationalefor this approach must be clearly documented in the medical record. Medical recordsmust be available and submitted upon request.”

So even though you can prove medical necessity per the LCD for the performanceof the post-op pain block, you must explain why an additional physician had to do theblock other than the surgeon or anesthesiologist in the case. But beware. One LCD pol-icy should in no way be interpreted and used as an overall coding policy.

— Cristina Bentin, CCS-P, CPC-H, CMA

SEPARATELY PAYABLE? If you take the timeto read Local Coverage Determination, you’llknow whether you can expect to be reimbursedfor a nerve block for preemptive analgesia.

Review your state’s LCD policies atwww.cms.hhs.gov/determinationprocess/04_lcds.asp

ON THE WEB

Where’s the detailed descrip-tion of the procedure? The clarifi-cation of the provider performingthe block? The differentiationbetween the anesthesia for thesurgery and the post-op painblock? Follow these documenta-tion recommendations

• Clarify which provider provid-ed the post-op pain service. Whoadministered the block — the sur-geon, the anesthetist performinganesthesia for surgery or someoneelse? AMA and CMS differ inguidelines; verify with carriers.

• Provide the completedescription of the block (what,when, why, where, how and medsused) and ensure it isseparate/distinct from anesthesiafor the surgery. Indicate the med-ication (steroid, neurolytic oranesthetic); specify the method(catheter, ablation or injection);list the site (cervical, thoracic orlumbar); specify temporary ver-sus permanent placement ofcatheters; and indicate the specif-ic condition or diagnosis.

• Ensure there is separate/dis-tinct documentation apart fromop note describing the surgery.

• Suggest the surgeon dictatethe reason for the transfer of careto another provider (medicalnecessity) when warranted.

Ultimately, expect that you’llneed to verify documentation andprovider requirements for carri-ers that allow separate reportingof post-op pain blocks. OSM

Ms. Bentin (cristina@ccmpro.com), afrequent contributor, is the principal at

Coding Compliance Management.

OC T O B E R 2009 | OU T PAT I E N T SU R G E RY MA G A Z I N E 5 1

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