The History of the TAP Block in Anesthesia
Summary
The specialty of anesthesiology is focused on a dual challenge to address patient pain but reduce the use of opioids. Nerve blocks are being seen as playing an important in addressing these objectives. New codes for TAP blocks have been introduced. Adoption of them is slower than expected but the potential may be significant.
In 2015 CPT added four new codes for transverse abdominis plane blocks (TAP blocks) that was first introduced as a new acute pain modality in 2001. Prior to the establishment of these codes these abdominal nerve blocks could only be billed with the code for other peripheral nerve block (64450), which was essentially a workaround. With the new codes providers had four options:
- * 64486-unilateral, single shot
- * 64487-unilateral, continuous
- * 64488-bilateral, single shot
- * 64489-bilatteral, continuous
While these blocks are quite popular in some practices for a number of commonly performed abdominal procedures such as colectomy, total abdominal hysterectomy, inguinal hernia, caesarian section, laparoscopic cholecystectomy, and gastric bypass, not all anesthesiologists see the value of these blocks and usage is very inconsistent from client to client. To wit, we have had some interesting discussions of the clinical potential of their use. Billing data from the ABC client base indicates that there was a significant increase in the number of TAP blocks billed once the new codes were established and understood. 2015 billings were up 24 percent and 2016 billings were up 38 percent. Since then the rate of increase has declined to 165 in 2017 and 14 percent in 2018.
The use of nerve blocks for post-operative pain management is growing in popularity across the country because it is believed to be safer and more effective than the alternative, which may involve opioids. A common point of reference is the use of interscalene blocks for shoulder surgery. Not all providers in a practice may be equally competent in performing nerve blocks for post-operative pain management, but the use of ultrasonic guidance in 2007 appears to greatly enhance the likelihood of a safe and positive outcome.
The use and relevance of nerve blocks for post-operative pain management appears to address three important issues with which the specialty is currently consumed: minimizing the use of opioids, lowering pain scores for greater patient comfort, and reducing opioid-related side effects. In recent years a patient's pain score has become the fourth vital element providers should monitor.
The Department of Health and Human Services commissioned an interagency task force to review current protocols for post-operative pain management. "The Pain Management Best Practices Inter-Agency Task Force (Task Force) was convened by the U.S. Department of Health and Human Services (HHS) in conjunction with the Department of Defense (DOD) and the Veterans Administration (VA) with the Office of National Drug Control Policy (ONDCP) to address acute and chronic pain in light of the ongoing opioid crisis."
"The ongoing opioid crisis lies at the intersection of two substantial public health challenges—reducing the burden of suffering from pain and containing the rising toll of the harms that can result from the use of opioid medications." - Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use; National Academies of Sciences, Engineering, and Medicine, 2017.
While there are only a handful of CPT procedure codes recognized for acute pain techniques there is an increasing number of commonly performed approaches for the management of post-operative pain. The most common ones are 64415 for interscalene blocks, 64445 for sciatic blocks and 64447 for femoral blocks. It is not entirely clear why TAP blocks were recognized so quickly by the AMA and included in the CPT code book. The fact that they were, though, is significant and has encouraged adoption across the country.
As with any new technique or approach, acceptance may be slow as providers come to master the technical skills necessary and appreciate the potential clinical value. ABC data with regard to client use of TAP blocks is consistent with the statement below from a December 2014 article in the Journal of the American College of Surgeons entitled Demonstrating the Benefits of Transversus Abdominis Plane Blocks on Patient Outcomes in Laparoscopic Colorectal Surgery: Review of 200 Consecutive Cases:
"A growing body of evidence supports the use of TAP blocks for a variety of abdominal procedures, yet, widespread adoption of this therapeutic adjunct has been slow. In part this may be related to the limited sources for anesthesiologists to develop an appreciation for its sound anatomical basis and the versatility of it clinical application."
At ABC we do not consider ourselves qualified to assess and opine on the clinical efficacy of new pain modalities and techniques. We leave such determinations to organizations such as the AMA. Our primary focus is educational. We want our clients to be aware of their clinical and billing options. We leave determinations of appropriateness and relevance to the individual provider. While the clinical studies supporting the use of TAP blocks for abdominal procedures may not yet be 100 percent conclusive they are definitely compelling and thousands of patients are benefiting from these blocks every year.
If you have questions about the documentation and billing requirements for TAP blocks or questions about how your utilization of these blocks compares to other practices feel free to reach out to your account executive.