May 30, 2023

I can still remember that line from the classic comedic film, The Blues Brothers. When asked by the blues band’s front man what type of music is usually performed at this particular venue, the bar owner’s wife says with an assuring smile and a cosmopolitan confidence, “Oh, we have both kinds—country AND western!” The band knew they were in for a long night.

It’s always good to have options; but, often, those options can be limited. And so it is when it comes to anesthesia providers and postoperative pain (POP) blocks. Here, we’re not talking about the various types of pain blocks available to the anesthesia practitioner. After all, the choice seems endless. There are epidurals and spinals, delivered in a single shot or via continuous catheter. There are iPACK blocks and TAP blocks and any number of peripheral nerve blocks. No, the limit is not in the type of POP block available to the anesthesia provider but rather in his or her ability to get reimbursed for such blocks when used in combination with certain modes of anesthesia. In other words, your ability to be paid for these blocks is directly tied to the anesthesia technique you utilize during the case. Let’s dive a bit deeper.

In General Terms

Let’s talk first about POP blocks in connection with a general anesthetic. When the anesthesia technique is a general, receiving reimbursement for such blocks is generally unimpeded. Assuming it’s a block that the payer normally covers, it matters not when you place the block. It could be preoperatively placed, post-operatively placed or placed during the surgical session; as long as the mode of anesthesia is a general, then the covered POP block should be separately reimbursed by the payer.

In other words, you can be confident that, unless the block you’re employing is never covered by the payer due to  its experimental nature or it not yet having been assigned a CPT code, the POP block will typically get paid when the anesthesia for the case is a general. This statement betrays the fact that reimbursement for postoperative pain procedures may be in question if the mode of anesthesia is anything other than a general. Let’s now turn to those scenarios.

In the Region of Maybe

When it comes to using a regional block as the main anesthetic for the case, obtaining separate reimbursement for postoperative pain procedures is going to be potentially difficult, being dependent upon a couple of key factors. The primary rule goes something like this: If your mode of anesthesia is a regional block, you cannot bill separately for post-op pain where the POP block is essentially the same as the block used for the interoperative portion of the case. For example, if you used an epidural for the case anesthetic, you cannot additionally bill for a POP epidural. Similarly, if you use a femoral nerve block for the case anesthetic, you would not be able to bill separately for a femoral POP block.

The Correct Coding Initiative (CCI) is a program within the Centers for Medicare and Medicaid Services (CMS) that is tasked with determining the bundling rules for coding and billing. Here’s what the introduction to the Anesthesia section of the CCI has to say on this subject:

A peripheral nerve block injection (CPT codes 64XXX) for postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection.

So, if the mode of anesthesia is either a general, spinal or epidural, you can bill a peripheral nerve block separately for postoperative pain—as long as the intraoperative anesthesia is not dependent upon that nerve block. Notice also that the above CCI excerpt does not say anything about getting paid for a POP peripheral nerve block where a peripheral nerve block is also the mode of anesthesia. Indeed, the CCI goes on to state in a later section that, if a peripheral nerve block is the mode of anesthesia, you cannot bill separately for either a POP peripheral nerve block or a POP epidural where such POP procedures are placed preoperatively or intraoperatively.

Getting back to the above excerpt, you’ll notice that there is one mode of anesthesia that is conspicuously absent. We will examine that in more detail below.

The Only Option for MAC

The above CCI excerpt involving peripheral nerve blocks for postoperative pain deliberately excludes monitored anesthesia care from the list of anesthesia techniques. The implication is that the provider may not bill separately for peripheral nerve blocks used for postoperative pain management when the anesthesia mode is MAC. The CCI goes on to clarify its position relative to POP blocks and MAC:

An epidural or peripheral nerve block injection administered preoperatively or intraoperatively is not separately reportable for postoperative pain management if the mode of anesthesia for the procedure is monitored anesthesia care . . . .

So, the rule of thumb is that MAC and POP blocks don’t play well together. The authors of the CCI believe that a postoperative pain procedure performed prior to, or during, the surgery would provide some measure of anesthetic relative to the operative session. If this is the case, it would be inappropriate to separately bill for postoperative pain. However, this does leave one possibility: if you perform the POP block after the surgical session where MAC was used as the mode of anesthesia, then the CCI leaves the door open for separate payment. Notice the excerpt immediately above specifies blocks that are placed preoperatively or intraoperatively. It says nothing about postoperatively. Accordingly, to get paid for POP blocks where the mode of anesthesia is MAC, the provider will have to place the block after the surgery. That way, there is no possibility of the block being used as the anesthetic for the operative session.

In conclusion, anesthesia providers will need to be aware of the limitations on reimbursement for postoperative pain procedures where the mode of anesthesia for the case is anything other than a general. In cases involving the two other modes of anesthesia, postoperative placement of POP blocks may be the better strategy—at least from a payment perspective.

With best wishes, 

Rita Astani
President—Anesthesia