The use of peripheral nerve blocks before, during or after orthopedic procedures can save minutes in the OR, reduce the need for post-op opioids and speed patient recoveries. But reimbursement for these time- and cost-effective injections depends on properly administering, documenting and billing them. The following guidelines, which also apply to catheterizations for local anesthesia infusion pumps, can help you get paid painlessly.

1. Don't mingle with Medicare. First and foremost, it's not advisable to bill peripheral nerve blocks to Medicare. Unlike most private payors, the program considers their use an integrated component of the orthopedic surgeon's overall efforts, not a separately billable service for the anesthesia provider and facility. When the patient is covered by a private payor, however, nerve blocks are billable by the anesthesia provider and the surgical facility in addition to their respective billings for the primary anesthesia necessary for the case and the surgery's technical component.

Only in rare and extreme circumstances are nerve blocks billable to Medicare. One such example would be in the event that the injection wasn't planned ahead of time, but was deemed necessary for post-op pain control once the orthopedic procedure was concluded. The supporting medical records submitted to Medicare should make it very clear that it was out of the ordinary for this step to be taken, since it would be considered planned and expected if it were carried out in this manner on a regular basis.

2. Divide up the duties. In order to net the separate reimbursement for a nerve block, a provider other than the surgeon who is performing the orthopedic surgery must administer the injection. However, it can be and usually is given by the same anesthesiologist or CRNA that is administering the general anesthesia or other primary anesthesia for the case.

A failure to comply with this guideline will result in a denied claim for the surgeon (because these blocks are unbundled in the CCI edits from the procedure, when performed by the same physician) or, to the anesthesia provider and facility (for whom the code is billable, except to Medicare), a paid claim that must be recompensed to the payor.

The surgeon himself must order the nerve block's administration for post-op pain, and this order must be documented in the chart. An anesthesia provider doesn't have the authority to take this action independently without potentially arousing a payor's suspicions of self-referral.

3. Distinguish the block's purpose. A regional anesthesia technique is only billable as a service separate from the anesthesia charge if it is administered only to pre-empt post-op pain — post-op pain relief must be its sole purpose in a procedure — and it must not be the only anesthesia administered during the case.

This requires that the primary anesthesia delivered during a case, whether general anesthesia, spinal anesthesia or deep sedation with airway assistance, effectively sedates the patient for surgery without the help of the nerve block. It also means that if the nerve block is the main method of anesthetizing a patient for a procedure, it cannot be billed separately, as payors will then consider it the primary anesthesia component.

Some coding and billing advisors have further recommended that nerve blocks be administered outside of the OR in order to physically distinguish the post-op procedure from the surgical procedure for the benefit of payors. While starting blocks in pre-op, a procedure room or PACU may economize on OR time, it's not necessary for billing purposes. The location in which a pre-induction or post-emergence nerve block placement is performed is of no consequence and can be done in the OR as long as the time it takes to place the block is billed separately and not grouped in with the anesthesia time for the surgery itself. (If the block is placed during the procedure, however, the time doesn't need to be deducted.)

4. Separate the paperwork. In order for your facility and your anesthesia provider to be reimbursed for the administration of a nerve block as a separate procedure, it must be documented separately and its claim must be filed separately. The op report or procedure report for this post-op pain control intervention should not be part of the anesthesia record or the orthopedic surgeon's op report.

The best practice is for the nerve block to be billed on a separate claim form from the claim for the orthopedic surgery procedure, and for the anesthesia provider to be listed as the performing provider on the claim. In the eyes of payors, the treatment for post-op pain is a separate and distinct procedure, as though it were the only procedure being performed on the patient that day, and the separate paperwork will help demonstrate the distinction.

While the anesthesia provider will list the appropriate diagnoses for the case itself on his op report, the 338.18 diagnosis code indicating acute post-op pain will be billed on the separate form to support the use of the nerve block, along with notes on the surgeon's request for it, the type of block (by specific CPT code), the description of the procedure and whether it was performed pre- or post-operatively.

If, however, the payor with whom the claims for the surgery and the nerve block are being filed takes issue with receiving 2 separate claims on the same patient, on the same date of service, consider billing on a UB-04 claim form. On this form, which allows the listing of 2 providers, the orthopedic surgery procedure and the nerve block placement charges can all be accounted for at once.

5. Mind your modifiers. No special modifiers need to be used in billing for a nerve block placement. Even though ASCs are generally required to append the —TC modifier when they bill to recoup the facility fee for procedures that involve a technical as well as a professional component, it's not necessary to append the —TC modifier in nerve block billing.

Appending the —59 modifier, which identifies a procedure as being performed as a separate procedure from other procedures performed on the same date of service, is unnecessary if the nerve block is billed on a separate claim form from the orthopedic surgery.

If the nerve block is billed on the same claim form as the surgery, though — when using a UB-04 form, for example, as described above — then the —59 modifier should be appended, but only if the post-op pain control technique is unbundled from the orthopedic procedure being billed (as is the case with most private payors, but not with Medicare). Finally, use the —RT or —LT modifier as usual on the procedure code for a nerve block to indicate on which side of the patient's body the block was placed.

Inside the lines
As a medical subspecialty, post-op pain management is still a young field. There's a lot of opportunity for profit in it, but from a payor's point of view there's also the potential risk for fraud. Peripheral nerve blocks and other interventions may not be medically necessary, or necessary as often as they're performed, so strict billing rules help payors to keep them under scrutiny. Staying within these guidelines, however, will help to make sure you're reimbursed for your efforts.