Making the Rounds: A Closer Look at Postoperative Pain Visits

​Summary
Pain rounds may be an overlooked or uncertain part of an anesthesia practice from a billing or compliance perspective. Today's article seeks to bring clarity to this topic so that anesthesia providers are more informed about how they might be correctly compensated for this important service.

In recent weeks, we have provided our readers with a number of articles that touched on the topic of postoperative pain (POP) blocks. These were important publications to provide given the near ubiquitous use of these procedures among anesthesia groups today. We've discussed this subject from a billing, coding, and practice management perspective. We've talked about how to document these blocks and how to get paid for these blocks. With today's alert, we'd like to close the loop on this conversation by addressing what may be thought of as the final stage of the post-op pain process: the pain round.

Defining the Round

Perhaps we should begin by defining our terms and describing this process. Rounding, of course, refers to a provider visiting a patient for the purpose of ascertaining his or her current condition. But not all rounds are equal. For example, a pain round is not the same as a post-anesthesia round. The base units associated with the anesthesia code that appears on the claim form already contains a payment component that accounts for the time and work the provider is expected to expend in typical post-anesthesia care. In other words, you cannot get paid extra for the post-anesthesia round. However, in certain circumstances, you can obtain separate payment for rounds that are intended to evaluate the effects of a separately billable postoperative pain procedure (or where a continuous epidural is used for both the anesthetic and postoperative pain).

Timing of the Round

The first criterion for payment relative to a pain round is that the round must fall within a certain time window. Postoperative pain procedures typically come with a "0" global period, meaning that you can get paid for a provider visit, i.e., round, beginning the day after the procedure. So, to state it another way, you cannot bill for a round that was performed on the same day as the pain block, but you can bill for certain pain rounds beginning the day following the block. This reflects one side of the time window. On the other side, Medicare may pay for pain rounds up to three or four days subsequent to the day of the block placement, depending on the jurisdiction. Rounding beyond this time will require satisfactory justification in the medical record and may involve a medical necessity review by the federal intermediary. Commercial payers may have differing guidelines as to the number of days they will reimburse relative to rounds, or no guidelines at all.

Classification of the Round

There are two distinctly different types of pain rounds. They involve different codes, different levels of reimbursement and different documentation protocols. The first of these involves what we commonly refer to as the "daily pain round." It is reflected by CPT code 01996, whose code descriptor is as follows: "Daily hospital management of epidural or subarachnoid continuous drug administration." The second type of round involves a patient who does not have an indwelling epidural or spinal catheter. These are typically billed out with the appropriate evaluation and management (E/M) codes from the subsequent hospital care code set, i.e., 99231-99233. The primary dividing line between these two types of rounds, then, is the presence of an epidural/spinal catheter. If it's in place during the round, you can bill the higher-paying 01996 daily pain round code; if not, you will bill the applicable E/M code, typically 99231. As to this latter scenario, we should point out the following:

• For most payers, it would be appropriate to bill an E/M service where a peripheral nerve continuous catheter is in place during the round, such as a femoral nerve catheter. You are rounding on a patient that still has pain medication being infused at the time of the round, and so there is medical necessity for the round in that circumstance.
• For some payers, it would be appropriate to bill an E/M service where the patient received a spinal injection, in which Duramorph was the injected agent. Since this narcotic tends to last much longer in its effects, many payers would deem a round on the subsequent day to be medically necessary.
• In any other single-shot, non-catheter scenario (e.g., single-shot interscalene block), billing for a pain round on the succeeding day may be deemed by many payers as not meeting the medical necessity threshold. We would expect submission for payment in such circumstances to be rare.

Documenting the Round

When you're rounding on a patient with an epidural (or spinal) catheter in place, your documentation should include something about the epidural catheter and associated drug delivery system, along with other patient-specific items. When rounding on a patient who does not have an epidural/spinal catheter in place, you'll want to document a typical E/M note, which focuses on a patient history, exam and some level of medical decision-making. Below are some bullet points you might want to include in your round documentation:

Acute Postoperative Daily Management of Epidural (Code 01996 )

• Details regarding the patient's level of pain and subsequent relief
• Medication plan
• Exam of placement site
• Any side effects
• Catheter status (For example, if catheter removed during that visit, a note such as "catheter removed," "catheter removed tip intact," etc. should be present. If the catheter is not being removed during visit, a note in the plan such as "continue catheter," "continue epidural," etc. should be present.)
• Provider signature
• Date of service

Acute Postoperative Daily Management of Blocks such as Continuous Brachial Plexus Blocks, Continuous Femoral Nerve Blocks, Continuous Sciatic Nerve Blocks, and Post-op Duramorph (Codes 99231-99233 )

• Review of the medical record
• Review of diagnostic studies and changes in the patient's status since the last assessment by the physician
• Requires a problem-focused interval history and exam
• Provider signature
• Date of service

Even if you document one or two sentences for the history and exam elements, that is usually enough to justify payment for a low-level subsequent hospital visit, i.e., 99231—at least as it pertains to most insurers. Of course, there are the odd payers who will have different payment rules when it comes to rounds. For example, Medi-Cal (Medicaid of California) does not pay for pain rounds at all.

Announcing the Round

Remember that it does no good, from a payment perspective, to document the round if we never see the round note. Providers with "hard-copy" records sometimes forget to send in their round progress note. For those using EMRs, there can be hiccups, as well. These systems often have a module for documenting such ancillary services, but the data from these modules may not be translating to our billing team. We encourage you to confirm with your facility's EMR or IT staff that your electronic documentation of pain rounds is reaching our office.

Postoperative pain rounds may reflect a small portion of your overall services, but it is still well worth your efforts to ensure you are being appropriately compensated for your time, care and expertise.