Postoperative Pain Management Procedures can Still be Reported Separately From the Anesthesia Service

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Editor's note: This article by Tony Mira, president and CEO of Anesthesia Business Consultants, an anesthesia & pain management billing and practice management services company, originally appeared in Anesthesia Business Consultants eAlerts, a free electronic newsletter. Sign-up to receive this newsletter by clicking here.

A change to some language in the Anesthesia Services chapter of the Medicare National Correct Coding Initiative manual recently created considerable confusion among participants in the online discussion maintained by the Medical Group Management Association (MGMA) for the Anesthesia Administration Assembly (AAA).

The information that gave rise to the confusion has been clarified. The NCCI has confirmed that there has been no policy change here; epidurals and blocks placed preoperatively for the management of postoperative pain are still separately reportable and not bundled into the anesthesia service unless they are used as the method of administering the anesthesia itself. Because the issue of post-op pain management is a perennial hot topic, we take this opportunity to help ensure that no incorrect interpretations take root.

Chapter II of the NCCI manual, "Anesthesia Services," (pdf) was revised effective Jan. 1, 2012. It contains a number of statements that are consistent with the established principles of billing a separate code for postoperative pain management, including the following, with emphasis supplied:

• CPT codes 62310-62311 and 62318-62319 (Epidural or subarachnoid injections of diagnostic or therapeutic substance) may be reported on the date of surgery if performed for postoperative pain management rather than as the means for providing the regional block for the surgical procedure. If a narcotic or other analgesic is injected postoperatively through the same catheter as the anesthetic agent, CPT codes 62310-62319 should not be reported for postoperative pain management. However, if epidural or subarachnoid injections are not utilized for operative anesthesia, but are utilized for postoperative pain management, modifier 59 may be reported to indicate that the epidural/subarachnoid injection was performed for postoperative pain management rather than intraoperative pain management. (Page II-7)
• Example: A patient has an epidural block with sedation and monitoring for arthroscopic knee surgery. The anesthesia practitioner reports CPT code 01382 (Anesthesia for diagnostic arthroscopic procedures of knee joint). The epidural catheter is left in place for postoperative pain management. The anesthesia practitioner should not also report CPT codes 62311 or 62319 (epidural/subarachnoid injection of diagnostic or therapeutic substance), or 01996 (daily management of epidural) on the date of surgery. CPT code 01996 may be reported with one unit of service per day on subsequent days until the catheter is removed. On the other hand, if the anesthesia practitioner performed general anesthesia reported as CPT code 01382 and at the request of the operating physician inserted an epidural catheter for treatment of anticipated postoperative pain, the anesthesia practitioner may report CPT code 62319-59 indicating that this is a separate service from the anesthesia service. In this instance, the service is separately reportable whether the catheter is placed before, during, or after the surgery. (Page II-9)
• CPT codes 64400-64530 (Nerve blocks) may be reported on the date of surgery if performed for postoperative pain management. Nerve block codes should not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique. Modifier 59 may be utilized to indicate that a nerve block injection was performed for postoperative pain management, rather than intraoperative anesthesia, and a procedure note should be included in the medical record. (Page II-10)

Unfortunately, another part of Chapter II contains a single sentence that could be interpreted to prevent billing for a preoperative or intraoperative pain procedure that also provided any analgesia during the operation. And it was misinterpreted, in the course of a December compliance webinar attended by many anesthesiologists and anesthesia practice managers. The problem sentence is underlined in the manual excerpt below:

[I]f the epidural or nerve block is administered preoperatively or intraoperatively, the epidural or nerve block is separately reportable by the anesthesia practitioner only if the epidural or nerve block is not utilized for intraoperative pain management. An epidural or nerve block that provides intraoperative pain management even if it also provides postoperative pain management is included in the 0XXXX anesthesia code and is not separately reportable. The anesthesia practitioner may report modifier 59 to indicate that the epidural or nerve block was performed for postoperative pain management, not intraoperative pain management, and a procedure note should be included in the medical record. (Page II-11)

The issue became, in the online discussion among the AAA members, whether payors or auditors would now deny claims for postoperative epidurals and nerve blocks if these provided any intraoperative pain management even though they were administered for postoperative pain control. It is virtually impossible, of course, to place an epidural or block before or during general anesthesia without affecting intraoperative pain.

The medical director of the NCCI, Niles R. Rosen, MD, was quickly contacted for clarification by the attorney who gave the webinar where the controversy arose. Dr. Rosen responded informally and pointedly as follows:

However, I think that some of your clients may be imputing an incorrect sinister intent to the underlined statement. From the context of the paragraph, it is clear that CMS acknowledges that a nerve block for post-op pain management may be administered preoperatively, intraoperatively, or postoperatively. Clearly, a nerve block administered preoperatively will provide some intraoperative analgesia. Thus, the underlined statement should NOT be interpreted to suggest that preoperative nerve blocks primarily for post-op pain management are not separately reportable because they also provide some intraoperative analgesia when the primary mode of intraoperative analgesia is separate and distinct. CMS may choose to rephrase the underlined sentence to provide clarity.

I will write you again after CMS considers this inquiry. Our current NCCI agenda with CMS is quite full, but I hope that we can address this issue in the next 4-6 weeks.

Thus, no less an authority than the NCCI medical director has affirmed the rule that nerve blocks and epidurals placed preoperatively or intraoperatively for the purpose of postoperative pain management, and not as part of the primary anesthetic, may be reported in addition to the anesthesia service. Stanley W. Stead, MD, MBA, chair of the ASA Committee on Economics, restated ASA's long-standing position to the same effect in the AAA discussion: "The issue is that when an epidural or nerve block is used for intraoperative pain management, it is considered part of the anesthetic and is bundled in the anesthesia CPT code. Regardless of when the block is placed, preop, intraop or postop, the service may be separately reportable using modifier 59, if it is used solely for postoperative pain management." (Emphasis in original). A longer response to the proliferation of AAA questions promptly appeared as a "Washington Alert" on the ASA website.

Should further official sources be necessary, e.g. if a claim is rejected or in case of disagreement between compliance professionals, we refer the reader to ASA's comprehensive statement and explanation entitled "Reporting Postoperative Pain Procedures in Conjunction with Anesthesia," which appears on pp. 57-64 of the 2012 Relative Value Guide and is also hyperlinked from the Washington Alert referenced earlier.

Practice tip: Documentation and coding

First, make sure that you add modifier -59 (distinct procedural service) to the code for the epidural or nerve block used for postoperative analgesia and not as the primary route for the anesthetic agent.

As coding expert Kelly D. Dennis, MBA, reminded us in the AAA discussion, it is important to adopt an auditor's perspective when documenting pain procedures performed on the same day as an anesthetic. What will help the auditor see quickly whether the purpose of the block or epidural was pain management? According to Ms. Dennis, the documentation should demonstrate, in particular:

1. Surgeon requested POP [postoperative pain management]. Notes & Clues 1) Routine POP is surgeon's responsibility per CCI; 2) As with any medical service provided to a patient, it is determined on a case-by-case basis; 3) Per 1997 ASA resource, if surgeon does not document the request for POP, the anesthesia provider may indicate their requested participation; 4) an indication via separate form, note/comment or area on the anesthesia record that indicates requested by surgeon.
2. Anesthesia for the surgery was not dependent on the regional technique. Clues - 1) general anesthesia was provided for the surgery and 2) an indication via separate form, note/comment or area on the anesthesia record that indicates POP was not mode of anesthesia.

The ASA statement on Reporting Postoperative Pain Procedures also offers guidance on documentation:

One excellent means of portraying that the block was a postoperative analgesic is to dictate or record its conduct in the chart in a location separate from the anesthetic record. When documenting, it is important to discuss that the surgeon requested that the anesthesia team participate in the provision of postoperative analgesia, that the patient was involved in the process of defining the best plan for such analgesia and that the patient received additional information about the risks and procedures of such therapy and consented to the procedure, separate from the information attendant to informed consent for the anesthetic. (Emphasis in original)

We hope that everyone is now clear again on whether anesthesiologists may bill for regional anesthesia techniques separately from the anesthetic when the block or epidural is used primarily for postoperative pain management — and that neither payors nor inartful language will make another round of explanations necessary.

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The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.

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