By: Cindy Triplett, CPC, CANPC, CPMA, Senior Director, Anesthesia Education
Linda Duckworth, CHC, CPC, Director, Provider Education & Advisory Services
Ventra Health continues to field questions from Anesthesia practitioners about the appropriateness of billing for post-operative pain management. This always takes us back to the documentation being the deciding factor. In this Compliance Series blog, we will dig into the CMS requirements around post-operative pain management.
Compliance Risks With Post-Operative Pain Management Billing
Being overly aggressive with billing post-operative pain management could have severe consequences for Anesthesia groups. Awareness of payer policies and bundling guidelines is crucial to compliant billing. According to the National Correct Coding Initiative (NCCI) manual, chapter two, page II-6, “Postoperative pain management services are generally provided by the surgeon who is reimbursed under a global payment policy related to the procedure and shall not be reported by the Anesthesia practitioner unless separate, medically necessary services are required that cannot be rendered by the surgeon. The surgeon is responsible for documenting in the medical record the reason that care is being referred to the Anesthesia practitioner.” If the Anesthesia group fails to adhere to this concept, overpayments could result. Collaboration and communication with the surgeons will lessen these risks.
Reporting the Separate Services
Post-operative pain management is included in the surgeon’s global payment. However, surgeons may request an Anesthesia practitioner to assist when medically reasonable and necessary, and when the actual or anticipated postoperative pain is severe enough to require expertise from anesthesiology.
For reference, Ventra Health created the table below using scenarios from the NCCI manual:
| Pain Procedures | Coding Scenario | |
|---|---|---|
| ✅ | Peripheral nerve blocks ‣ 64XXX-59 or XU | Report with Anesthesia codes 0XXXX if the mode of intraoperative Anesthesia is general, subarachnoid, or epidural when the adequacy of the intraoperative Anesthesia is not dependent on (or supplemented by) the peripheral block. |
| ✅ | Epidurals ‣ 623XX-59 or XU | Report with Anesthesia codes 0XXXX if the mode of intraoperative Anesthesia is general, when the adequacy of the intraoperative Anesthesia is not dependent on (or supplemented by) the epidural injection. |
| ❌ | Peripheral nerve blocks ‣ 64XXX Epidurals ‣ 623XX | Do not report either code set for post-operative pain management if the Anesthesia (for the procedure) was monitored Anesthesia care, moderate/conscious sedation, regional Anesthesia by peripheral nerve block or other type of Anesthesia not mentioned above. |
Reminder, in December 2022, CPT assistant published guidance stating that fascial plane blocks should be reported with 64999.
Modifiers Impact Payment
Since billing separately for the peripheral nerve blocks and epidurals is considered unbundling, add modifier -59 or modifier XU (non-overlapping service) to the codes (644XXX/623XX) when performed on the same day as the surgery. The modifiers act as an attestation that the qualifications for separate payment were met. The medical records must reflect the same.
Must the pain intervention take place after the operative procedure?
The epidural or peripheral nerve block can be administered either preoperatively, intraoperatively, or postoperatively. The determinant is the procedure’s intent rather than the procedure’s timing. It must have been ordered by the surgeon with the intent to provide post-operative pain management, regardless of when it takes place, and this must be distinctly documented by the surgeon.
Documentation Enhancement
- Take every opportunity to emphasize to the surgeons the significance of documenting their request, along with the intent, medical necessity, and the anticipated type of post-surgical pain management intervention(s).
- Create detailed Anesthesia notes that fully illustrate the indications, laterality, anatomical location, preparation, description of the service(s) (including ultrasound), complications, start/stop times, and the induction time of the primary anesthetic for the surgical case.
What’s Next and How Ventra Health Can Help
Ventra Health takes compliance very seriously. The guidelines put forth by various regulating bodies, while sometimes complicated or inconvenient, are critical to follow closely. Our Provider Education team has launched this Compliance Blog Series to help you navigate the complexities of compliance and coding changes.
In case you missed it, check out our previous post in the series:
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