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Common coding challenges: Use 4 post-op block FAQs to strengthen your coding, protect your revenue

Post-op blocks are a major source of revenue for anesthesia practices, but the rules confuse providers and coders, putting their claims at risk.
Share the following four questions from a recent APCPS post-op blocks webinar to prevent denials that can’t be appealed:
Question: Is medical direction broken when an anesthesiologist performs a post-operative block?
Answer: Start by checking with your carrier. “Some carriers have published frequently asked questions that state that acute pain management procedures and blocks are OK. Some carriers leave it up to the individual provider’s discretion,” Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, president, Perfect Office Solutions, Leesburg, Fla., said during the webinar.
For example, Palmetto released a list of FAQs that indicate post-operative blocks will not break medical direction:
“As long as the medically directing anesthesiologist ‘remains physically present and available for immediate diagnosis and treatment of emergencies’ (rule 6 of the CMS ‘seven requirements’), we agree that the following procedures would be an illustrative but not exclusive list of allowed interventions …
“2. Placement of an epidural catheter for post-operative analgesia or in preparation for subsequent surgery (for a ‘to follow case’)
“3. Placement of other peripheral nerve blocks prior to subsequent surgery, to include brachial plexus blocks, ankle blocks, femoral nerve blocks, etc.” Novitas also allows doctors to run all forms of blocks while medically directing.
“An anesthesiologist may perform and, if otherwise eligible, seek reimbursement for procedures (such as arterial line insertions; central venous catheter insertions; pulmonary artery catheter insertions; and epidural, spinal and peripheral nerve blocks) in an area immediately available to the operating room and when performance of such services do not prevent him/her from being immediately available to respond to the needs of the surgical patients.”
Note that both carriers emphasize that the anesthesiologist has to be immediately available to the patients under the care of the certified registered nurse anesthetists (CRNAs) he is medically directing. “Look at where the blocks are being done. Where are the CRNAs?” Dennis said.
Ask a carrier for a written opinion on post-op blocks and medical direction if it hasn’t released a statement. “Ask the state anesthesia association or the American Society of Anesthesiologists [ASA] if you want to ask anonymously,” Dennis said.
Question: Can orders for post-op blocks be verbal?
Answer: The surgeon may place a verbal order for a post-operative block, but the verbal order must be documented — and they can get lost, Dennis cautioned. The best practice is to get a separate written order from the surgeon. When that doesn’t happen, you might be able to find documentation that supports the request in the surgeon’s note. Remind anesthesia providers and administrative staff that a block performed without a documented request is a block that can’t be billed.
As auditors ramp up their scrutiny of anesthesia services, blocks performed without the request will be an easy target, but it may not take an audit to stop payments. For example, during her presentation, Dennis noted that Cigna will not process a claim for a block without documentation that supports medical necessity. In addition, practices should review the ASA’s guidance on post-op blocks, Dennis said.
Question: We’re receiving denials on hospital visit 99231 reported for post-op block rounds when the anesthesia provider who performed the block bills the visit. The carrier says that in those circumstances, the visit is bundled with the anesthesia care.
Answer: “There are no global days associated with those codes, so you should be able to get paid on appeal,” Dennis said.
Denials highlight the importance of creating complete documentation for every service. Without it, there is no way to appeal a denial. Make sure staff understand the requirements for the hospital visit as well as the post-op block.
Question: How do we bill a saphenous block?
Answer: Saphenous blocks don’t use a specific code, but it is a peripheral nerve block and may be reported with 64450 (Other peripheral nerve block), Dennis said.