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Summary
The growing use of nerve blocks for acute pain management is helping anesthesiologists improve the quality and safety of patient care.  New approaches and techniques are emerging all the time.  While this innovation benefits patients, it also creates billing and coding challenges and underscores the importance of having a billing partner that understands this area and stays current with changes in the CPT® Codebook.

September 4, 2018

Most anesthesia practices have found that nerve blocks for acute pain management provide a valuable opportunity to improve postsurgical outcomes, enhance the quality and safety of care, and increase patient satisfaction.  Steady innovation within the specialty has yielded many new safe and effective nerve block approaches and modalities, including the quadratus lumborum and IPACK blocks (see below).

As new nerve block techniques and approaches emerge, coding and billing for acute pain management services evolve as well.  A uniqueness of anesthesia billing is that most anesthesia charges are calculated based on the difficulty of the surgical procedure and the amount of time required to manage the anesthetic.  However, payment for nerve blocks (often performed with ultrasonic guidance) is made according to the Current Procedural Terminology (CPT®) Fee Schedule in a manner similar to most other medical procedures.  This creates an ongoing challenge for billing and coding professionals to ensure that billing and coding not only accurately reflect surgical complexity and anesthesia time, but also capture the appropriate CPT code(s) for the acute pain management service or services provided.

Please note that three main pieces of information are needed to bill a nerve block for postoperative pain management:

  1. When the block was performed: before or after induction
  2. Confirmation that the block was performed for postoperative pain management
  3. Confirmation that the block was performed at the request of the surgeon

Providing this information to your coding and billing partner will help ensure proper payment.

Complicating the ever-evolving billing and coding scenario is the fact that many of the relatively new nerve block approaches have yet to be recognized and included in the CPT code list.  The AMA revises and updates the CPT codes annually, but the CPT code list often does not keep pace with the creation and adoption of new acute pain management approaches and techniques within the specialty. As a result, payers must often manually adjudicate the coding and billing of many of the acute pain management services for which a CPT code is not yet available. These “unlisted” services are often billed using CPT code 64999 (Unlisted Procedures of the Nervous System).  However, unlisted procedure codes are seldom reimbursed by many carriers. A billing and coding team that is attuned to acute pain management changes and strategies to ensure proper payment helps greatly in this regard.

For most of the recognized and accepted nerve block modalities, the CPT code list generally includes specific codes for the following delivery options:

  • Single injection, unilateral
  • Single injection, bilateral
  • Continuous catheter insertion

However, not all of these standard nerve blocks have codes for each of these options. 

For example, for the interscalene block for shoulder procedures, CPT code 64415, single injection of the brachial plexus is coded, and CPT code 64416 is the corresponding code for a catheter insertion. Although the CPT code list recognizes two other approaches for an injection of the brachial plexus in addition to interscalene—suprascapular and axillary—it recognizes only the interscalene approach for a catheter insertion.

Similarly, a bilateral brachial plexus injection does not have its own code; however, this procedure can be indicated with the bilateral modifier (-50). 

Sciatic injections offer another example of how CPT codes do not always reflect new developments. Currently, there are two codes for sciatic injections: CPT code 64445 for a single injection and CPT code 64446 for a catheter insertion.  However, many anesthesia practitioners now use a popliteal approach for sciatic injections. The CPT code list has not yet assigned a specific code for this approach, and CPT code 64445 is the current AMA-recognized coding option.  (For reporting purposes, however, ABC uses its own code to distinguish between a traditional sciatic injection and a popliteal injection.)

The CPT Codebook was updated in 2015 to reflect anesthesiologists’ growing use of the transversus abdominis plane (TAP) block.  This procedure, previously unrecognized by CPT, now has codes for four options:  single shot unilateral, single shot bilateral, continuous unilateral and continuous bilateral.

The femoral nerve block (one of the most common nerve blocks, according to a recent ABC client survey) is coded with CPT code 64447 for a single injection and 64448 for a catheter insertion. Currently, the same codes also can be used for adductor canal and saphenous nerve blocks.

Acute pain management—and, by extension, acute pain management coding and billing—are always evolving as anesthesiologists continue to explore new approaches and techniques. For example, some anesthesiologists have recently begun performing a block in the interspace between the popliteal artery and capsule of the posterior knee, known as an IPACK block, to reduce pain after knee surgery and help minimize the need for opioids in immediate recovery.

Undoubtedly, other blocks will emerge soon. The challenge is to ensure the selection of an appropriate code in each case.  The AMA has a service to assist pain physicians with coding. However, all of these emerging techniques and coding options underscore the need to have a billing and coding team that understands the complexities of acute pain management.

ABC clients:  your account executive will be happy to assist in any way to enhance the value of your practice.

With best wishes,

Tony Mira
President and CEO