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A Primer on Coding in Regional Anesthesia and Acute Pain Management

Aug 1, 2019

Kamen Vlassakov, MD, Melanie Donnelly, MD, MPH, and Jeff L. Xu, MD

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Authors

Kamen Vlassakov, MD
Member, ASRA Practice Management Committee
Director, Division of Regional and Orthopedic Anesthesia
Program Director, Regional Anesthesiology and Acute Pain Medicine Fellowship
Brigham and Women’s Hospital
Assistant Professor of Anesthesiology
Harvard Medical School
Boston, MA

Melanie Donnelly, MD, MPH
Medical Director
Lone Tree Surgery Center
Associate Professor of Anesthesiology
University of Colorado School of Medicine
Aurora, CO

Jeff L. Xu, MD
Chief of the Division of Regional Anesthesia and Acute Pain Management
Program Director, Regional Anesthesiology and Acute Pain Medicine Fellowship
Clinical Assistant Professor of Anesthesiology
Department of Anesthesiology
Westchester Medical Center/New York Medical College
Valhalla, NY

Introduction

Proper coding is essential for correct billing and fair reimbursement. Errors in coding carry potential for financial loss and risk for serious legal consequences. The Current Procedural Terminology (CPT) codes are developed, main-tained, and updated annually by the American Medical Association (AMA). They are used to uniformly identify med-ical, surgical, and diagnostic services and procedures. While most of the CPT codes for anesthesia are closely related to surgical procedures, procedural codes for regional anesthesia are relatively independent. Most of them are listed among the codes for surgery of the nervous system. Certain conditions must be met when these regional anesthetic procedures are performed in the context of perioperative care and in addition to the main anesthetic modality.

For example:

  • CPT codes 64400 to 64530, describing peripheral blocks (single injections or continuous infusions), “may be reported on date of surgery if performed for postoperative pain management only if the operative anesthesia is general anesthesia, spinal, or epidural and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block. Peripheral nerve block codes should not be reported separately if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique.”
  • If the mode of anesthesia is monitored anesthesia care, conscious sedation, or peripheral block and the block is administered pre- or intraoperatively, it cannot be separately reported for postoperative pain management.
  • The pain management procedure must be requested by the surgeon (postoperative pain management is bundled with the payment to the surgeon).
  • If the nerve block procedure is billed separately, no time units may be billed.
  • The follow-up, including monitoring, troubleshooting, bolusing, etc, of continuous epidural or peripheral nerve block catheters can only be billed on subsequent days, excluding the day of catheter placement. No more than one unit may be billed per day regardless of the number of visits required to manage the catheter.


Commonly Used Codes

 

Procedural Notes

For correct documentation and billing of region-al anesthesia and analgesia procedures, it is critical to provide procedural notes that fully reflect important, relevant medical aspects and that strictly comply with administrative requirements. Omitting key features of the procedural note could result in penalties from Centers for Medicare and Medicaid Services.
Key features of procedural notes for peripheral blocks include:

  • Procedure order: Peripheral block, single injection vs catheter
  • Before placement of block:
    • Patient examined, chart reviewed
    • Discussion about risks and benefits, specifics as indicated
    • Verification of anticoagulation status*
    • Person giving consent: patient, caregiver, other Reason for block: anesthesia vs postoperative pain control
    • Indication of request by attending surgeon, if applicable (surgeon must also place an order documenting the request for consultation)
    • Procedure timing: Pre-, post-, intraoperative and location

* For patients undergoing perineuraxial, deep plexus, or deep peripheral block, we recommend that guidelines regarding neuraxial techniques be similarly applied (grade 1C). For patients undergoing other plexus or peripheral techniques, we suggest management (performance, catheter maintenance, and catheter removal) based on site compressibility, vascularity, and consequences of bleeding, should it occur (grade 2C)[1]

  • Nerve block procedure:
    • Preprocedural time out, including review of indications and contraindications
    • Sterility, nerve block type (single injection vs continuous catheter placement), location of block
    • Laterality of block
    • Sedation level
    • Positioning for block
  • Nerve block needle/catheter utilized
    • Gauge, length, etc
  • Nerve localization**
    • Ultrasound, fluoroscopy, stimulation, etc
    • Image interpretation (ie, surrounding target, lateral to target, etc)
    • Image quality
    • In plane vs out of plane
    • Visualization of needle
    • Image saved/archived

** Example of documentation for ultrasound image: Ultrasound was used live throughout the procedure, to identify all neural structure/plane, and appropriate perineural placement of local anesthetic and needle with in plane technique.

  • Nerve block injection and dosing: medications, including visualization of medication administration on imaging
  • Block events:
    • Paresthesias, pain, resistance, blood, positive test dose, multiple attempts, etc
  • Staff performing and supervising procedure

Key features of procedural notes for placement of epidurals include:

  • Procedure order: Epidural block
  • Before placement of epidural block:
    • Patient examined, chart reviewed
    • Conversation about risks and benefits, specifics as indicated
    • Status of anticoagulation, including last dose of subcutaneous heparin, verified
    • Person giving consent: Patient, caregiver, other
    • Reason for block: Anesthesia vs postoperative pain control
    • Indication of request by attending surgeon, if applicable (surgeon must also place an order documenting the request for consultation)
    • Procedure timing: Pre-, post-, intraoperative and location
  • Epidural procedure
    • Preprocedural time out, including review of indi-cations and contraindications
    • Sterility
    • Sedation level
    • Final positioning
    • Apparent interspace
    • Approach: Midline vs paramedian
    • Image guidance, including interpretation of imag-es
  • Epidural needle and catheter
    • Needle length and gauge
    • Technique: Loss of resistance (LOR; saline or air), hanging drop, etc
    • LOR at what distance
    • Catheter at skin
    • Imaging employed (yes/no)
  • Ultrasound, fluoroscopy, stimulation, etc
  • Image interpretation (ie, surrounding target, lateral to target, etc)
  • Image saved/archived
  • Image quality
  • In plane vs out of plane
  • Visualization of needle
  • Epidural management
    • Aspirations, dosing
  • Events/actions
    • Paresthesia, pain, blood, positive test dose, cere-brospinal fluid, spinal onset, multiple attempts
  • Staff performing and supervising procedure

References

  1. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based guidelines (4th Ed). Reg Anesth Pain Med. 2018 Apr; 43:263-309.
  2. Centers for Medicare & Medicaid Services. National correct coding initiative edits. Available at https://www.cms.gov/Medicare/Coding/NationalCorrectCo-dInitEd/index.html. Accessed June 15, 2018.

Kamen Vlassakov, MD, is the director of the Division of Regional and Orthopedic Anesthesia and program director of the Regional Anesthesiology and Acute Pain Medicine Fellowship at Brigham and Women’s Hospital and an assistant professor of anesthesiology at Harvard Medical School in Boston, MA. He serves as member of the ASRA Practice Management Committee. Melanie Donnelly, MD, MPH, is the medical director of Lone Tree Surgery Center and an associate professor of anesthesiology at the University of Col-orado School of Medicine in Aurora, CO. Jeff L. Xu, MD, is chief of the Division of Regional Anesthesia and Acute Pain Management, program director of the Regional Anesthesiology and Acute Pain Medicine Fellowship, and clinical assistant professor of anesthesiol-ogy in the Department of Anesthesiology at Westchester Medical Center/New York Medical College in Valhalla, NY.

The authors would like to thank Laura Wnukowski, CCS-P, Sr. Revenue Manager, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, for generously sharing her time and expertise in support of our project.

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