Best Practices: Documentation and Reporting for Post-Operative Pain Management Procedures in Anesthesia

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Anesthesiologists often grapple with how to accurately report post-operative pain management procedures. Historically, epidurals and blocks that are placed pre-operatively for the purpose of managing post-operative pain are separately reportable and not bundled into the anesthesia service itself. The exception to this general rule is when the epidural or block is the anesthetic itself. Anesthesia for surgical procedures is reported with CPT codes 00100-01999. With only a few exceptions, these codes do not specify the type of anesthesia administered. Blocks done as part of a combined technique were never separately reportable. However, single shot nerve blocks performed pre- or intra-operatively for the intended purpose of post-operative pain control do not represent a combined technique. Similarly, a catheter placed pre- or intra-operatively is not part of a combined technique even if a small test dose is administered to confirm catheter placement, provided that the test dose is not intended to provide surgical anesthesia and does not, in fact, produce surgical anesthesia. The intended purpose of the single shot block or catheter placement is dependent upon the specific clinical situation, and the anesthesiologist's documentation should clearly describe the circumstances and purpose of the block.

When it comes to getting paid for post-operative pain blocks, not all payors require the same documentation and proof of medical necessity. Some commercial carriers follow the Medicare edits and guidelines while others do not follow Medicare reimbursement — potentially allowing for more aggressive coding and reporting. While most pain management providers are usually on target when describing injection procedures, the ball gets dropped too often when it comes to documenting post-operative pain blocks. Detailed documentation is essential and the post-op pain injection must be separate and distinct from the anesthesia used to perform the surgery. To ensure best practices with respect to reporting post-operative pain procedures in conjunction with anesthesia procedures, consider the documentation advice below:

  • Administer the post-operative pain block pursuant to a surgeon's request;
  • Document the time spent administering the block separately from the anesthesia time, unless the pain block was administered after induction and prior to emergence;
  • Attach a modifier -59 when applicable;
  • Document the method for administering the block separately from the method for administering the surgical anesthesia;
  • Indicate the purpose or the reason for the block as well as the specific site of pain; and
  • Indicate the type of block or catheter that was performed.

Many commercial carriers that allow separate reporting advise a separate operative report or procedure note for the injection. Likewise, many commercial carriers have medical necessity and provider requirements.
For instance, when considering modifier -59, CPT codes submitted with modifier -59 attached are considered appropriate coding to the extent they follow the American Medical Association CPT book. The CPT codes should designate a distinct or independent procedure performed on the same day by the same physician, but only to the extent that:

  1. Although such procedures or services are not normally reported together they are appropriately reported together under the particular presenting circumstances; and
  2. It would not be more appropriate to append any other CPT recognized modifier to such CPT codes.

The submission of modifier -59 appended to a procedure code indicates that documentation is available in the patient's records for review upon request that will support the distinct or independent identifiable nature of the service submitted with modifier -59. CPT codes submitted with modifier -59 attached will be eligible for payment to the extent they not only follow the AMA CPT book, but additionally are not considered a bundled component of a more comprehensive code or two codes that should not be reported together by Regence reimbursement policy based on NCCI edits, NCCI coding guidelines or Regence CCE edits. 

AMA guidelines

The AMA says it is appropriate to report pain management procedures for post-op analgesia separately from the administration of a general anesthetic. "Whether the block procedure (insertion of catheter; injection of narcotic or local anesthetic agent) occurs pre-operatively, post-operatively or during the procedure is immaterial," reads AMA CPT OCT 01; 9. Keep in mind that even though the AMA allows for separate reporting under specific circumstances, commercial carriers might have varying reporting and billing policies.

American Society of Anesthesiologists guidelines

According to the American Society of Anesthesiologists in its "Reporting Post-Operative Pain Procedures in Conjunction with Anesthesia," a provider can bill for a regional anesthetic technique as a service separate from the anesthetic if the regional technique is employed primarily for post-operative analgesia and if the following conditions apply:

  • The anesthesia for the surgical procedure was not dependent upon the efficacy of the regional anesthetic technique. For example, if an interscalene nerve block is placed prior to shoulder surgery to affect prolonged post-operative analgesia, then a general anesthetic would have to be used for the actual shoulder surgery rather than simply I.V. sedation in order to properly report the regional block separately. In this setting, if the patient was provided a block and only sedation was added, then it would be clear that the interscalene block was a part of the primary anesthetic rather than a mode of post-operative analgesia.
  • The time spent on pre- or post-operative placement of the block is separate and not included in reported anesthetic time. Post-operative pain blocks are most frequently placed before anesthesia induction or after anesthesia emergence. When the block is placed before anesthesia time starts or after it has ended, the time spent placing the block should not be included in reported anesthesia time; this is true irrespective of what level of sedation and monitoring is provided to the patient during that block placement.
  • Time for a post surgical pain block that occurs after induction and prior to emergence does not need to be deducted from reported anesthesia time. Time spent on the placement of the post-operative pain block that occurs after induction and prior to emergence is included in reported anesthesia time. In such cases, it is not necessary to report discontinuous anesthesia time. Sedation given expressly to facilitate placement of the block should not be included in reported anesthesia time. One way to portray that the block was a post-operative analgesic is to dictate or record its conduct in the chart in a location separate from the anesthetic record.

The ASA has recently received reports of payors inappropriately bundling the placement of epidurals and peripheral nerve blocks for post-operative pain control into the payments for surgical anesthesia services. This is contrary to CPT guidance, CCI edits, Medicare contractors’ instructions and the process used to assign base unit values to anesthesia codes. In all probability, this bundling is due to payor confusion regarding the difference between regional anesthesia that is applied as a part of the primary anesthetic as opposed to that which, while placed prior to the onset of anesthesia, is intended primarily to provide post-operative analgesia.

CMS National Correct Coding Initiative

CMS issued its annual National Correct Coding Initiative edits at the beginning of 2013. The NCCI Manual still provides the following clarification on single shot epidurals as described by CPT codes 62310 and 62311, which also notes that these specific procedures may be separately reported from an anesthesia service when they meet the criteria:

"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 post-operative pain management rather than as the means for providing the regional block for the surgical procedure. If a narcotic or other analgesic is injected post-operatively through the same catheter as the anesthetic agent, CPT codes 62310-62319 should not be reported for post-operative pain management. However, if epidural or subarachnoid injections are not utilized for operative anesthesia, but are utilized for post-operative pain management, modifier -59 may be reported to indicate that the epidural/subarachnoid injection was performed for post-operative pain management rather than intraoperative pain management."

But while CMS has not made significant changes in 2013, anesthesia providers should still be aware of new post-operative pain management coding changes. New 2013 NCCI edits suggest certain post-operative pain management procedures may only be separately reportable with anesthesia if the mode of the anesthesia is general. Specifically, the NCCI edits set forth for some of the following additions:

  • Epidural injections for post-operative pain management are separately reportable with anesthesia only if the mode of intraoperative anesthesia is general anesthesia and the adequacy of the intraoperative anesthesia is not dependent on the epidural injection;
  • Epidural injections or peripheral nerve block injections administered pre-operatively or intraoperatively are not separately reportable for post-operative pain management if the mode of anesthesia for the procedure is monitored anesthesia care, moderate conscious sedation, regional anesthesia by peripheral nerve block, or other type of anesthesia (i.e., if the mode of anesthesia is not general);
  • Epidural or subarachnoid injections utilized for intraoperative anesthesia and post-operative pain management are not separately reportable on the day the epidural or subarachnoid catheter were inserted; rather, the epidural or subarachnoid catheter may be reported for pain management beginning the day after insertion through discontinuance; and
  • Management of epidural or subarachnoid drug administration (CPT code 01996) is separately payable on dates of service subsequent to surgery, but not on the date of surgery. If the only service provided is management of epidural/subarachnoid drug administration, then an evaluation and management service should not be reported in addition to CPT code 01996. Payment for management of epidural/subarachnoid drug administration is limited to one unit of service per post-operative day regardless of the number of visits necessary to manage the catheter per post-operative day (CPT definition).

Peripheral nerve block injections administered for post-operative pain management are only separately reportable with anesthesia 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.

Reporting epidurals or peripheral nerve blocks in conjunction with anesthesia must be accompanied by a modifier -59, which indicates that the epidural or block was administered for post-operative pain management.

As shown, these new edits do not vary from past NCCI guidance, but anesthesia providers must still remember that post-operative pain management is separately reportable when the mode of anesthesia is general and not when the mode is MAC, moderate conscious sedation or regional.

In conclusion, physicians should not report time or work related to separately billable services such as post-operative pain management procedures or invasive monitoring procedures. Additional services and payment for these procedures should not be bundled with the anesthetic service for an anesthetic code that does not include the work of provision of these. Physicians would be wise to keep all payor rules and guidelines in mind as they document and report procedures, since not all payors require the same documentation and proof of medical necessity. Doing so will ensure minimized compliance risks and optimized reimbursement for post-operative pain procedures.

Roxann Neisner is an operations manager II for the Great Lakes region of Medical Management Professionals, Inc., working out of the Charleston, W.Va., office. She has more than 30 years of overall experience in healthcare specializing in medical billing and practice management and has worked extensively in specialty practices including anesthesiology, radiology, pathology, vascular and general surgery. Ms. Neisner joined MMP in September 2000 and is a member of the Medical Group Management Association and the West Virginia Medical Group Managers Association.

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