July 17, 2023

All charges for anesthesia services can be lumped into three categories based on how they are paid. The majority of charges are time-based surgical charges where the charges and payments are calculated on the base value plus time and modifier units multiplied by a conversion factor. Obstetric charges involve a value based on the outcome of the delivery plus time, which may be calculated based on a number of different methodologies. Because payment methodologies vary considerably, it is always useful to analyze labor epidural payments as a separate category of services. The third category includes all the non-time-based services and procedures that are typically paid from a fee schedule that has nothing to do with the values in the Relative Value Guide (RVG), published by the American Society of Anesthesiologists (ASA). This third category includes charges for invasive monitoring, nerve blocks for acute pain management, ultrasonic guidance and a variety of other services such as Evaluation and Management (E/M) services.

Valuing the Invasive

When the RVG was first developed in the 1970s, specific criteria were envisioned to determine when a particular service was included in the anesthesia charge and when it could be separately billed. The initial distinction was based on whether the procedure was invasive; in other words, it involved the creation of a separate orifice. Thus, the use of arterial lines, central venous pressure lines and Swan-Ganz catheters were the first services to meet this criterion. This distinction reflected the reality that patients requiring these services were sicker than most and that the providers who performed these services had to have specialized training and skill to use them optimally in the management of cardiac patients.

Over the years, the concept of what is “invasive” has evolved considerably. Today, for example, transesophageal echocardiography (TEE) probe placement is considered an invasive service by most. The good news for cardiovascular anesthesiologists is that payers have never questioned the value of these services and payment levels have remained fairly consistent, especially on Medicare fee schedules.

Billing for Blocks

As American medicine has evolved over the years, the big question has had to do with unbundling. When is it appropriate to bill separately for a given service? This has become a hot topic in anesthesia where the use of nerve blocks for post-operative pain management has experienced dramatic growth, especially for orthopedic cases. It is now considered appropriate care to enhance the administration of the primary anesthetic with interscalene, sciatic and femoral blocks. The current literature supports a new standard of care that minimizes the use of opioids and enhances patient comfort. Most serious shoulder procedures are now performed with interscalene blocks. Femoral nerve blocks have become the norm for hip and leg procedures. The documentation requirements for payment are as follows:

• The block is not part of the primary anesthetic.
• The block is performed for enhanced post-operative pain management; and
• The block is performed at the request of or with the consent of the surgeon.

So long as these criteria are met, most insurance plans will pay separately for these procedures. A couple of years ago, codes were added for TAP blocks.

The three most common blocks performed for post-operative pain management are interscalene, sciatic and femoral. Payers had recognized the value of these procedures and had been willing to pay for the use of USG to ensure their accuracy. It is interesting to note, however, that when four new codes were added for TAP blocks a couple of years ago. USG was bundled into the TAP block codes. This, it turned out, was a preview of the future of payment for USG. 

There is yet another interesting aspect of the growth in the use of nerve blocks. Not only has the volume of claims increased dramatically over the past decade, but so has the use of alternative techniques. The following is a list of specific nerve blocks that has yet to be recognized by the editors of the CPT code book. What this means is that these services must be billed as unlisted procedures and there is no guarantee of payment.

• Cervical Plexus
• I Pack
• Erector Spinae
• Quadratus Lumborum

Time will tell if these are eventually added into CPT and onto payer fee schedules.

One final category of flat fee services related to follow-up care that may be appropriate for patients involves Duramorph injections. These visits are appropriate when medical necessity is documented, and the service is not provided on the same day but instead the following day. 

At the end of the day, some providers may be interested in the financial potential of unbundled services, but they must be careful. Ultimately, flat fee services are only separately payable when their value can be well documented and when they are not a new standard of care.  If you have questions about the payments you are receiving for your flat-fee services, please contact your account executive.  

With best wishes, 

Rita Astani
President—Anesthesia