The compliant reporting of peripheral nerve blocks for treatment of postoperative pain can bring additional facility reimbursement, but complex reporting guidelines and inconsistent payer reimbursement creates challenges.
Facility Payment for Surgical Anesthesia and Post-Operative Pain Blocks
Medicare Global Surgery Rules prevent separate payment for postoperative pain management when provided by the surgeon, however, Chapter II of the NCCI Policy Manual notes that facilities may report nerve blocks if certain criteria met:
For facility reporting, a separate code for nerve blocks with the appropriate modifier may only be reported when the documentation supports the nerve blocks were administered for post-surgical pain management. When the nerve block is considered part of the anesthesia process, it is not appropriate to report the block separately.1
The manual further notes that block must be administered by an anesthesia provider, as requested by the operating surgeon, specifically for the treatment of postoperative pain.
Since the pain block cannot be reported if it serves as the surgical anesthesia, another form of anesthesia must be administered. CMS has defined the qualifying anesthesia modalities as general, spinal, and epidural. Monitored anesthesia care, moderate conscious sedation, regional anesthesia by peripheral nerve block do not qualify.
So, your facility has documentation that the CRNA provided general anesthesia along with a nerve block, at the surgeon’s request, for treatment of postoperative pain. Your documentation meets the requirements, but will you be reimbursed?
NCCI PTP Edits
The ASC is subject to the Practitioner, rather than Hospital, Procedure-To-Procedure Coding Edits. These code pairings reflect the same provider for both comprehensive and component procedures, and do not account for an exception when a different provider performs the block. The edit is noted with a modifier indicator of 0, not allowed, per standards of medical / surgical practice. This edit will often result in denials, even when modifier 59 is reported. Therefore, some payers that reimburse for postop pain blocks require that the block is billed on a separate claim. It is important to verify correct billing practice. Adding a note, such “block (644xx) performed by anesthesia for postoperative pain” in box 19 of the CMS 1500 may be another reporting method.
Timing of Block
The NCCI Manual clarifies blocks may be given at any time during patient care:
An epidural or peripheral nerve block injection (62320-62327 or 64400-64530 as identified above) for postoperative pain management in patients receiving general anesthesia, spinal (subarachnoid injection) anesthesia, or postoperative pain management in patients receiving general anesthesia, spinal (subarachnoid injection) anesthesia, or regional anesthesia by epidural injection as described above may be administered preoperatively, intraoperatively, or postoperatively.
Report the diagnosis that required surgery. It may be best for the provider to make an actual diagnosis of postoperative pain, rather than document as an indication, if the payer has a nerve block medical necessity policy that lists postoperative pain (ICD-10 G89.18). Other supporting diagnoses may include the anatomical site-specific pain codes; however payer policy is not consistent, and may exclude them from coverage.
Documentation of Blocks in the Medical Record
Some payers may prefer a separate procedure note however the anesthesia note should have the specific documentation (medication, route of delivery, type of block, indication) noted. The addition of a diagnosis box (i.e., postoperative pain, leg pain) will assist coding.
Facilities may administer drugs, such as Exparel (C9290), that have temporary pass-through payment as noted in Addendum BB of the CMS ASC Fee Schedule. It is important to note the dosage (133ml or 266ml). The drug is billed in units per mg(ml):
Example: C9290 x 133, C9290 x 266. Reimbursement is ~$1.33 per mg.
Varying MAC Policy
LCD/LCA are in effect from First Coast, Noridian, and NGS. These policies may not list the same covered diagnoses and may also exclude diagnoses such as anatomical pain codes, from coverage. Attention to these policies, which are subject to updates and revisions on the CMS website, is important for compliant Medicare reporting.
- NCCI Policy Manual for Medicare. CMS. (n.d.). Retrieved April 6, 2022, from https://www.cms.gov/medicare/national-correct-coding-initiative-edits/ncci-policy-manual-medicare