Spring 2010

The Billing Nuances of Post-Op Pain

Hal Nelson, CPCN
Director of Compliance and Client Services, ABC

The variety of commonly used modalities for the management of post-operative surgical pain makes it imperative that practitioners understand the specific documentation and billing requirements of each option. Listed below are the five most common approaches and their corresponding claims submission guidelines. As is always the case, reimbursement will vary by payer.

  • Intravenous Patient-Controlled Analgesia Management (IV PCA) – Surgeons are reimbursed for routine post-operative pain management as part of their global fee. Due to this fact, Medicare does not allow anesthesiologists to bill for this service. However, many non-Medicare payers do. The physician must see the patient on a post-operative day and document a progress note to include a problem focused history and exam with straightforward medical decision making. The typical code billed for this service is “subsequent inpatient visit” code 99231 (2 units).
  • Patient-Controlled Epidural Analgesia (PCEA) – If an epidural is placed for post-op pain and is not the primary mode of anesthesia, it can be billed separately from the anesthetic with codes 62318 (cervical/ thoracic – 10 units) or 62319 (lumbar – 9 units). In addition, each calendar day of epidural catheter management is billable with code 01996 (3 units).
  • Spinals/Duramorph – If a spinal is placed for post-op pain and is not the primary mode of anesthesia, it can be billed separately from the anesthetic with code 62311 (8 units). In addition, a follow-up visit can be billed the next calendar day, if medically necessary. The typical code billed for this service is “subsequent inpatient visit” code 99231 (2 units). Keep in mind that some payers will bundle and deny any evaluation and management service billed the day after anesthesia. For combined spinal-epidurals commonly used in OB cases, it is not appropriate to bill separately for the spinal injection, since the injection is typically performed via the epidural catheter/trocar.
  • Interscalene/Brachial Plexus Blocks – If general anesthesia is used for a shoulder case, and an interscalene block is placed for post-op pain, the block can be billed for separately with code 64415 (8 units). If a continuous interscalene block is placed instead of a single stick, then code 64416 (13 units) is billed. For continuous blocks, there is no longer a global period, meaning that you can bill for follow-up visits if you physically see the patient on a subsequent calendar day. The typical code billed for this service is “subsequent inpatient visit” code 99231 (2 units).
  • Femoral and Sciatic Nerve Blocks – If a general anesthetic is used for a knee case, and a femoral and/or sciatic nerve block is placed for post-op pain, then the block(s) can be billed for separately with codes 64447 (femoral – 7 units) and/or 64445 (sciatic – 7 units). If a continuous block is placed instead, then report either code 64448 (continuous femoral – 12 units) or 64446 (continuous sciatic – 12 units). Follow-up visits can be billed if applicable, as mentioned above with the continuous brachial plexus blocks.
In conclusion, it is imperative to indicate that your block is separate and distinct from the primary mode of anesthesia used in the case when billing for post-op pain procedures. For example, groups should not check off both “general” and “regional” as the modes of anesthesia unless they are truly intending to do a combined “general-regional” technique, which would negate the separate billing of the block. Although most payers will allow a post-op pain block to be used as an adjunct to a general anesthetic, if the block itself could have provided the entire anesthetic, then documentation of medical necessity for the “general” is recommended. Per CMS requirements, anesthesiologists should state clearly on the anesthesia record that the block is “for post-op pain per surgeon request”. Per the AMA, post-op pain blocks can be performed either pre-operatively, intra-operatively or post-operatively. However, post-op pain blocks performed prior to the induction of anesthesia are not to be included in billable anesthesia time and are billed as “flat fee” surgical procedures instead, per the ASA.

Hal Nelson, CPC, Director of Compliance and Client Services for ABC is a nationally-known expert in the field of anesthesia, Nelson brings a variety of expertise to ABC clients in helping medical practices resolve anesthesia coding, billing and compliance challenges. His experience navigating through Medicare billing regulations, anesthesia and pain coding, payer audit defense, charge ticket review, compliance plan development and physician documentation analysis ensures ABC clients have a safety net for these challenging issues. He has 20 years experience on both the payer and billing side and is one of the specialty executives in charge of supporting sales, marketing, operations, auditing and compliance initiatives.