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Postoperative Pain Blocks: Taking Another Look

July 8, 2024

Astrophysicists had it right. Or so they thought. For decades, they held to certain assumptions about the early formation of the universe; but then came along the James Webb Space Telescope (JWST), which purportedly allows astronomers to look deeper into the past than what had heretofore been possible. And what the JWST is revealing is proving to be highly problematic for what had been the prevailing cosmogony models.

Sometimes, taking a second look or a deeper dive into a subject can lend new insights. We have published previous alerts concerning the subject of postoperative pain (POP) blocks, but with recent attention given to this topic by one of the large Medicare administrative contractors, it may be helpful to provide an update to the anesthesia community on all things POP.

Unchanging Principles

As we’ve affirmed numerous times in past articles and alerts, anesthesia providers are perfectly within the bounds of propriety to place an epidural or peripheral nerve block for the purpose of managing postoperative pain. When doing so, the provider is within his or her rights to receive reimbursement for this service, typically in the form of a flat fee. There are, of course, a few matters that must be observed and, in some cases, documented to obtain payment and to withstand the rigors of a Medicare audit. These include, in no particular order, the following:

  • There must be a transfer of pain management responsibilities from the surgeon to the anesthesia provider. After all, post-op pain control is already accounted for under the surgeon’s global fee. According to National Correct Coding Initiative (NCCI), which falls under the aegis of the Centers for Medicare and Medicaid Services (CMS), post-op pain management services must 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. To help support the medical necessity of the POP block claim, we continue to instruct our clients to document “at surgeon’s request” as part of their block note.
  • The anesthesia record should indicate who placed the block and make clear that the block was for postoperative pain control and not part of the main anesthesia for the intraoperative case.
  • The record should further reflect what type of POP procedure was utilized. If it was an epidural, was it thoracic or lumbar? If it was a nerve block, which nerve was implicated? Did the epidural or nerve block involve a single shot or continuous catheter? All these items should be clarified in the record.
  • Chapter II of the NCCI manual, which contains provisions related to anesthesia billing and bundling, makes it clear that certain POP blocks can only be billed in combination with certain anesthesia techniques. For instance, the NCCI states that a post-op pain epidural may be billed only if the mode of anesthesia is a general. Similarly, a POP nerve block is only payable where the anesthesia technique is a general, spinal or epidural. Regardless of the type of POP block employed, the NCCI states that the adequacy of the intraoperative anesthesia must not be dependent on the POP block. It then goes on to relate the following:

An epidural or peripheral nerve block injection administered preoperatively or intraoperatively is not separately reportable for postoperative 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 not identified above.

It should be noted that general anesthesia is identified in the paragraphs above. So, at the very least, the above excerpt indicates that you can bill a preoperatively or intraoperatively placed post-op pain block if the anesthesia for the case is a general. If MAC or a peripheral nerve block is the main anesthesia technique, then the preoperatively or intraoperatively placed POP block would be considered as augmenting the main anesthesia for the case and would, therefore, be non-reimbursable.

Most providers are already aware that they cannot bill a POP spinal or epidural if they were already utilizing a spinal or epidural as the main anesthetic for the case. For example, the NCCI notes: “An epidural injection for postoperative pain management may be separately reportable with an anesthesia code only if the patient receives a general anesthetic and the adequacy of the intraoperative anesthesia is not dependent on the epidural injection.”

Well now, that all seems clear enough, right? Maybe not.

Confusion at the Top

Recently, some confusion was added to the mix through the publication of a June 3 advisory from Noridian—the Medicare contractor for 10 western states (Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming)—stating the following: “An epidural or peripheral nerve block injection administered preoperatively or intraoperatively is not separately reportable for postoperative pain management.” But we’ve already read that the NCCI clearly allows a preoperatively or intraoperatively placed postoperative pain block as long as the main anesthetic for the case is not a MAC or peripheral nerve block. Furthermore, the NCCI goes on to explicitly state the following:

An epidural or peripheral nerve block for postoperative pain management in patients receiving general anesthesia, spinal 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.

After these sections of the NCCI were brought to the attention of Noridian’s in-house counsel, medical director and auditors by a prominent anesthesia compliance attorney during a late June Zoom call, Noridian reportedly reversed its position. In other words, the carrier agreed that there are circumstances when preoperatively and intraoperatively placed post-op pain blocks can be reimbursed—specifically those circumstances as outlined by the NCCI and cited above.

Nevertheless, that same Medicare contractor also reportedly added these requirements for reimbursement of POP blocks:

  1. Ensure there is a surgeon’s order, outlining the intent to turn over postoperative pain management to anesthesia. The anesthesia provider “may” refer to this order in their own block documentation.
  2. There must be documentation of a separate consent form signed by the patient for the block.
  3. There must be a separate procedure note for the block (not a check box), identifying that the patient was examined, what the clinical indications are for the block, how the procedure was performed, as well as the outcome of the procedure.

While Noridian may not have updated their position via their website as of the time of this writing, we recommend our clients in the western U.S. consider adding the above documentation elements to their pain note where they are not already doing so.

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