Billing talk

1. Optimizing Documentation for
Regional Anesthesia & Acute
Pain Medicine
Brian F.S. Allen
Associate Professor
Director, Regional Anesthesiology & Acute Pain Medicine Fellowship
Vanderbilt University Medical Center
July 27, 2022

2. Disclosures
No conflicts of interest.
Not a billing or coding professional!
My practice is hospital & ASC regional &
acute pain (APS)

3. Complexity
+“How do I bill this?”
+“That depends…”
+Multiple branch points exist when determining how to bill APS
services
+ Billing a procedure or an evaluation, inpatient or outpatient?
+ Was the procedure for surgical anesthesia or post-operative analgesia?
+ When was the procedure performed relative to surgery, anesthesia billing times, and
induction of anesthesia?
+ What type of procedure – block performed and single injection vs. catheter?
+ Private insurance or Medicare/Medicaid?
+ Is active analgesic management with follow-up evaluation planned?
+ What type of provider (physician vs. NP/PA) performs the follow-up?
+Current guidance could change in the future!!!

4. (OVER)Simplified Billing & Coding
Patient Care Documentation
Systematized Reporting
(Units)
Submission Payment
POINTS!

5. Anesthesia Billing Basics
+Billed services have 2 components
+ Professional component – Physician or provider services
+ Technical component – facility & equipment fees
+Services are billed by CPT (current procedural
terminology) codes +/- modifiers
+Each CPT code is assigned an RVU (relative value units)
AMA
Payment
Schedules
CPT RVU
Modifiers

6. Anesthesia Billing Basics
+Payers generally pay a rate per relative value unit (RVU)
+ Medicare conversion: $34.6062 (2022), $33.0775 (2023)
+ Anesthesia conversion: $21.5623 (2022), $20.7191 (2023)
+ Medicaid pays less, private payers generally pay more
+ Rate is modified by geographic location (GPCI)
+Anesthesia uses BASE + TIME billing
+ Each CPT has a number of “base units” AND then additional
units for time spent on a case (1 unit / 15 min)
+ Nerve blocks for surgical anesthesia are billed this way

7. Anesthesia Billing Basics
+Regional block procedures for postoperative
analgesia have their own CPTs without time units
+To bill for postoperative analgesia, a block must be
“separately reportable”
+RVUs for these blocks are calculated at higher
conversion rate ($ 34.6062 vs. $ 21.5623)
+Total RVUs billed are composed of 3 elements:
+ Work RVU, Practice Expense RVU, & Malpractice RVU
+ Sum of all 3 = Facility Total RVUs
CMS Physician Fee
Schedules 2021

8. Acute Pain Service
provided
What is being managed?
Purpose of procedure
Performing a
PROCEDURE
Analgesic management or
procedure FOLLOW UP
Epidural
follow-up
Anything
else:
Surgical
anesthesia
Postoperative
analgesia
Anesthesia
time-based
billing
Procedural
billing
(59 modifier)
Epidural
follow-up CPT
(01996)
E&M billing
APS Billing Decision Tree

9. Blocks and units – Peripheral blocks
Block Performed
Interscalene
Axillary brachial plexus
Axillary nerve
Suprascapular
Femoral
Adductor canal
Lumbar plexus
Infragluteal sciatic
Popliteal
Ankle
iPACK
Genicular
Block Billed (CPT single shot/catheter) Fac Total RVU
Brachial plexus (64415/16) 1.84 / 1.88
Axillary Nerve (64417) 1.77
Suprascapular (64418) 1.68
Femoral injection (64447/48) 1.54 / 1.77
Lumbar plexus injections, continuous
(64449)
1.82
Sciatic injection (64445/46) 1.57 / 1.81
Injection, anesthetic agent; other peripheral
nerve or branch (64450)
1.24
Injection(s), anesthetic agent(s) and/or
steroid; genicular nerve branches, including
imaging guidance when performed (64454)
2.38

10. Block Performed
TAP**
Rectus sheath**
Lumbar Epidural
Thoracic Epidural
Epidural blood patch
Paravertebral
Intercostal
Erector spinae
Ultrasound
Block Billed (CPT single shot/catheter) Fac Total RVU
TAP, rectus sheath, unilateral (64486/87)** 1.63 / 1.88
TAP, rectus sheath, bilateral (64488/89)** 2.02 / 2.27
Epidural w/o img guidance Lmbr/Sac
(62322)
2.37
Epidural W/ img guidance Lmbr/Sac (62323) 2.89
Epidural w/o img guidance Crv/Thrc (62324) 2.6
Epidural W/ img guidance Crv/Thrc (62325) 3.23
Epidural injection of blood (62273) 3.29
Paravertebral, single site (64461/63) 2.25 / 2.4
Paravertebral, subsequent sites (64462)* 1.43
Intercostal (64420 single; 64421 additional) 1.73 / 0.73
Injection, anesthetic agent; other peripheral
nerve or branch (64450)
1.24
Ultrasound guidance for needle placement
(76942)
0.79
Blocks and units – Neuraxial & Truncal
Code bundled with
some blocks (e.g., TAPs)

11. Separately Reportable – CMS wording
+ A peripheral nerve block injection (CPT codes 64XXX) for postoperative
pain management may be reported separately with an anesthesia 0XXXX
code only 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.
+ An epidural or peripheral nerve block injection (code numbers as identified
above) 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.
CMS
Rules

12. Purpose of the Block…
Separately Reportable?
Type of Surgical Anesthetic
(for EACH block performed)
Does the anesthetic plan depend
on the block performed?
General NOT General
Block for:
Postoperative
Analgesia
Block for:
Surgical
Anesthesia
Block for:
Postoperative
Analgesia
NO
YES
Bill as CPT Code
+ Modifiers
Bill as CPT Code
+ Modifiers
Bill as ASA units (base +
time units for anesthesia)
CMS
Rules

13. Modifiers
+22 – Challenging cases requiring extra care (e.g., severe scoliosis) – Requires
documentation
+25 – Significant, separately identifiable E&M service on the same day of a
procedure/service
+50 – Bilateral blocks (e.g., left and right femoral blocks)
+51 – Multiple procedures (e.g., femoral and sciatic blocks)
+52 – Decreased services (e.g., only 1 genicular nerve blocked)
+59 – Distinct procedural service
+ Used to show the block is different from the surgical anesthetic & separately billable
50% lower billing
on second block

14. Required Note Elements
+ Procedure type and details
+ Indication or diagnosis (ICD-10 pain
code)
+ Surgeon (provider) request
+ Date of service
+ Single injection vs. catheter
+ Name and signature of billing
provider
+ Procedure location and timing
+ Ultrasound if used
+ Image storage
+ Interpretation
+ Supervision statement (if applicable)

15. Other aspects of procedural billing
+Post-op pain blocks should be done at the request
of the surgeon
+ The more formal this request, the better
+ 1st choice: In surgeon note or orders
+ 2nd choice: In block note
+Ultrasound guidance CPT 76942
+ Document US use in chart
+ Image in chart or PACS system
+ Include a statement about interpretation
+ “US interpreted and normal except for ___”

16. Billing best
practices for
blocks
+ Communicate with billing and coding professionals
+ Crosswalk to the right codes
+ Avoid coding for “Other” block when possible
+ Store ultrasound images – electronic or physical copy
+ Interpret the ultrasound in your notes
+ Bill higher value code first when multiple procedures
+ Document surgeon’s block request as formally as possible -
this shows medical necessity of block
+ Attest when supervising – “present for all ultrasound
portions and all critical portions of the procedure”
+ Resubmit rejected bills
+ Negotiate with private insurers for >= 150% Medicare rates
per RVU
ASRA News
billing article

17. Service to be provided
What is being managed?
Purpose of procedure
Performing a
procedure
Analgesic management
or procedure follow-up
Epidural
follow-up
(days 2-4)
Anything
else
Surgical
anesthesia
Postoperative
analgesia
Anesthesia
time-based
billing
Procedural
billing
(59 modifier)
Epidural
follow-up CPT
(01996)
E&M billing
APS Billing Decision Tree
Next Up!

18. CPT Codes and Modifiers Relevant to Regional Anest
CPT Codes
62310-62319– Neuraxialblocks
64400-64530– Peripheralnerve blocks
01996 – Daily neuraxialcatheter management
76942 – Ultrasound guidance for needle placement
99251-99255– Inpatient consult (Private insurance)
99221-99223– Inpatient admit day (Medicare)
99233-99233– Inpatient subsequent days
CPT Modifiers
APS Service – non-procedural care
+Usually falls into 2 categories
+ Management of enteral or parenteral analgesics
+ Initial consultation for management
+ Follow-up management
+ Management of previously placed blocks
+ Indwelling peripheral catheters
+ Indwelling neuraxial (e.g., epidural) catheters
+ Follow-up of single injection blocks
+ Most of these billed with Evaluation and
Management (E&M) CPTs
CAVEATS!
Epidural f/u has its own CPT
Epidural f/u not billable by NPs/PAs
Epidural f/u starts on the day after
placement
Medicare pays 3 days epidural f/u

19. CPT Codes and Modifiers Relevant to Regional Anest
CPT Codes
62310-62319– Neuraxialblocks
64400-64530– Peripheralnerve blocks
01996 – Daily neuraxialcatheter management
76942 – Ultrasound guidance for needle placement
99251-99255– Inpatient consult (Private insurance)
99221-99223– Inpatient admit day (Medicare)
99233-99233– Inpatient subsequent days
CPT Modifiers
APS Service – non-procedural care
+Usually falls into 2 categories
+ Management of enteral or parenteral analgesics
+ Initial consultation for management
+ Follow-up management
+ Management of previously placed blocks
+ Indwelling peripheral catheters
+ Indwelling neuraxial (e.g. epidural) catheters
+ Follow-up of single injection blocks
+ Most of these billed with Evaluation and
Management (E&M) CPTs
CAVEATS!
Medicare/Medicaid does
not pay for inpatient new
consults
These are billed “admit day”

20. E&M Billing/Coding
• Three types of relevant E&M codes
• Inpatient Consult
• 1st day seen
• Not used for Medicare patients
• Inpatient admit day
• 1st day for Medicare patients
• Inpatient subsequent days
• For all other days for all patients (except epidurals)
• Each E&M service has different “levels”
• 5 levels for consults
• 3 levels for subsequent days or Medicare admit day
• Higher levels reimburse more
• Qualify for higher levels based on what is in the progress/consult note
• This system is complex and confusing… get ready for it!!!

21. Blocks and units – Peripheral blocks
Patient Mgmt
Inpatient Consultation
Inpatient Admit Day
Inpatient Follow Up
Day
Epidural Follow Up
Service Billed (CPT) RVUs
(2018)
Consult Level 1 (99251) 1.38
Consult Level 2 (99252) 2.11
Consult Level 3 (99253) 3.25
Consult Level 4 (99254) 4.72
Consult Level 5 (99255) 5.68
Inpatient Admit Day Level 1 (99221) 2.87
Inpatient Admit Day Level 2 (99222) 3.87
Inpatient Admit Day Level 3 (99223) 5.74
Inpatient Subsequent Day Level 1 (99231) 1.11
Inpatient Subsequent Day Level 2 (99232) 2.06
Inpatient Subsequent Day Level 3 (99233) 2.95
Epidural Follow Up (01996) 3

22. Determining the Level of E&M billing
+ Three main factors:
+ History
+ Composed of 3 elements
+ HPI elements – 8 possible
+ Location, Quality, Severity, Duration, Timing,
Context, Modifying factors, Associated
signs/sx
+ Review of systems - # systems reviewed
+ PFSH – Patient, Family, and Social History
+ Physical Examination
+ # of systems examined
+ Medical Decision Making
+ Itself composed of 3 elements
+ Type and # of presenting problems
+ Amount and complexity of data
+ Risk
Inpatient Consult
CPT Code 99251 99252 99253 99254 99255
History
HPI 1 - 3 1 - 3 4+ 4+ 4+
ROS None 1 2 - 9 10+ 10+
PFSH None None 1 All 3 All 3
Exam (# systems)
1 Area/
System 2 - 4 5 - 7 8+ 8+
Medical Decision
Making
St Fwd St Fwd Low Moderate High
1
2
3

23. Inpatient/Observation Admit Day
CPT Code 99221/18 99222/19 99223/20
History
HPI 4+ 4+ 4+
ROS 2-9 10+ 10+
PFSH 1 All 3 All 3
Exam (# systems) 5-7 8+ 8+
Medical Decision
Making
Straightforward
or Low
Moderate High
Determining the Level of E&M billing
Inpatient Consult
CPT Code 99251 99252 99253 99254 99255
History
HPI 1 - 3 1 - 3 4+ 4+ 4+
ROS None 1 2 - 9 10+ 10+
PFSH None None 1 All 3 All 3
Exam (# systems)
1 Area/
System 2 - 4 5 - 7 8+ 8+
Medical Decision
Making
St Fwd St Fwd Low Moderate High
Inpatient Subsequent Care
CPT Code 99231 99232 99233
History
HPI 1 - 3 1 - 3 4+
ROS None 1 2 - 9
PFSH None None None
Exam (# systems) 1 2 - 4 5+
Medical Decision
Making
Straightforward
or Low
Moderate High
Appropriate CPT code is
determined by the
SINGLE LOWEST score

24. Medical Decision Making
Decision Making Straightforward Low Moderate High
I. Presenting Problems 0 - 1 2 3 4
II. Amount of Data 0 - 1 2 3 4
III. Overall Risk Minimal Low Moderate High
I. Type and Number of Preseting Problems Points
□
Single self-limited or minor problem: stable,
improved, or worsening. Max=2
1
□
Established problem (to examiner): stable,
improved, resovling/resolved
1
□
Established problem (to examiner):
worsening, inadequately controlled
2
□
New problem to examiner: no additional work
up planned
3
□
New problem to examiner w/ additional
assessment, consult, or diagnostic studies
4
II. Amount and Complexity of Data Points
□ Review and/or order of clinical tests 1
□
Review and/or order of tests in CPT radiology
section
1
□
Review 2 and/or order of tests in CPT
medicine section
1
□
Discussion of test results with performing
physician
1
□
Independent review of image, tracing, or
specimen
2
□
Decision to obtain old records &/or obtain hx
from someone other than patient
1
□
Review and summarize old records and/or
obtaining hx from someone other than patient
2
Understanding Medical Decision Making
+Type & # of presenting problems
+Amount and complexity of data
+ Tests ordered & interpreted
+Level of risk involved with 3 areas
+ Presenting problems
+ Diagnostic procedures
+ Management chosen
+Overall MDM score looks at 3 areas,
ignores the lowest one
1
2

25. Table of Risk
Level of Risk Presenting Problems Diagnostic Procedures Ordered Management Options Selected
Minimal Self-limited or minor problem Lab test requiring venipuncture Rest
UA, Ultrasound Splints
Chest X-rays, EKG Superficial dressings
Low 2+ self-limited or minor problems, symptoms MRI/CT OTC drugs
1 stable chronic illness Superficial needle biopsies IV fluids w/o additives
Acute uncomplicated illness Clinical lab test req. arterial puncture PT/OT
Skin biopsies Minor surgery w/o identified risk factors
Moderate 1+ chronic illness w/ mild exacerbation,
progression, or side effects of tx
Diagnostic endoscopies w/o identified risk
factors Prescription drug management
Acute illness w/ systemic symptoms Physiologic tests under stress test IV fluids w/ additives
2+ stable chronic illnesses Arthrocentesis, LP Therapeutic nuclear medicine
Acute complicated injury Deep needle or incisional biopsy Minor surgery w/ identified risk factors
Undiagnosed new problem w/ uncertain
prognosis
Cardiovascular imaging studies w/ contrast,
no risk factors
Elective major surgery w/o identified risk
factors
Closed tx of fx or dislocation w/o
manipulation
High 1+ chronic illnesses w/ severe exacerbation,
progression or side effects of treatment
Cardiovascular imaging studies w/ contrast,
w/ identified risk factors
Administration of parenteral controlled
substances
Acute or chronic illness that may pose a
threat to life or bodily function
Diagnostic endoscopies w/ identified risk
factors
Drug therapy requiring intensive monitoring
for toxicity
An abrupt change in neurological status Cardiac EP test Elective major surgery w/ risk factors
Discography Emergency major surgery
Decision not to resuscitate or to de-escalate
care because of poor prognosis
Table of Risk Scored by HIGHEST in ANY 1 area

26. Medical Decision Making
Decision Making Straightforward Low Moderate High
I. Presenting Problems 0 - 1 2 3 4
II. Amount of Data 0 - 1 2 3 4
III. Overall Risk Minimal Low Moderate High
MDM examples
1. Case 1
+ 1 presenting problem
+ Amount of data – low
+ Risk – moderate
+ Overall MDM = Low
2. Case 2
+ 3 presenting problems
+ Amount of data – straightforward
+ Risk – high
+ Overall MDM = Moderate
3. Case 3
+ 4 presenting problems
+ Amount of data – high
+ Risk – straightforward
+ Overall MDM = High

27. Medical Decision Making
Decision Making Straightforward Low Moderate High
I. Presenting Problems 0 - 1 2 3 4
II. Amount of Data 0 - 1 2 3 4
III. Overall Risk Minimal Low Moderate High
MDM examples
1. Case 1
+ 1 presenting problem
+ Amount of data – low
+ Risk – moderate
+ Overall MDM = Low
2. Case 2
+ 3 presenting problems
+ Amount of data – straightforward
+ Risk – moderate
+ Overall MDM = Moderate
3. Case 3
+ 4 presenting problems
+ Amount of data – high
+ Risk – straightforward
+ Overall MDM = High

28. Medical Decision Making
Decision Making Straightforward Low Moderate High
I. Presenting Problems 0 - 1 2 3 4
II. Amount of Data 0 - 1 2 3 4
III. Overall Risk Minimal Low Moderate High
MDM examples
1. Case 1
+ 1 presenting problem
+ Amount of data – low
+ Risk – moderate
+ Overall MDM = Low
2. Case 2
+ 3 presenting problems
+ Amount of data – straightforward
+ Risk – high
+ Overall MDM = Moderate
3. Case 3
+ 4 presenting problems
+ Amount of data – high
+ Risk – straightforward
+ Overall MDM = High

29. Medical Decision Making
Decision Making Straightforward Low Moderate High
I. Presenting Problems 0 - 1 2 3 4
II. Amount of Data 0 - 1 2 3 4
III. Overall Risk Minimal Low Moderate High
Medical Decision Making
Decision Making Straightforward Low Moderate High
I. Presenting Problems 0 - 1 2 3 4
II. Amount of Data 0 - 1 2 3 4
III. Overall Risk Minimal Low Moderate High
Medical Decision Making
Decision Making Straightforward Low Moderate High
I. Presenting Problems 0 - 1 2 3 4
II. Amount of Data 0 - 1 2 3 4
III. Overall Risk Minimal Low Moderate High
MDM examples
1. Case 1
+ 1 presenting problem
+ Amount of data – low
+ Risk – moderate
+ Overall MDM = Low
2. Case 2
+ 3 presenting problems
+ Amount of data – straightforward
+ Risk – high
+ Overall MDM = Moderate
3. Case 3
+ 4 presenting problems
+ Amount of data – high
+ Risk – straightforward
+ Overall MDM = High

30. Inpatient/Observation Admit Day
CPT Code 99221/18 99222/19 99223/20
History
HPI 4+ 4+ 4+
ROS 2-9 10+ 10+
PFSH 1 All 3 All 3
Exam (# systems) 5-7 8+ 8+
Medical Decision
Making
Straightforward
or Low
Moderate High
Inpatient Subsequent Care
CPT Code 99231 99232 99233
History
HPI 1 - 3 1 - 3 4+
ROS None 1 2 - 9
PFSH None None None
Exam (# systems) 1 2 - 4 5+
Medical Decision
Making
Straightforward
or Low
Moderate High
E&M examples
1. Case 1
+ POD 1 follow-up on peripheral catheter
+ HPI – 3 points
+ ROS – 10 points
+ PFSH – 1 point
+ Exam – 5 systems
+ MDM – High
+ Overall – 99232
+ Level 2 Inpatient Subsequent Care
2. Case 2
+ New consult on post-op Medicare patient
+ HPI – 4 points
+ ROS – 9 points
+ PFSH – 3 points
+ Exam – 8 systems
+ MDM – High
+ Overall – 99221
+ Level 1 Inpatient Admit Day

31. Inpatient Subsequent Care
CPT Code 99231 99232 99233
History
HPI 1 - 3 1 - 3 4+
ROS None 1 2 - 9
PFSH None None None
Exam (# systems) 1 2 - 4 5+
Medical Decision
Making
Straightforward
or Low
Moderate High
Inpatient/Observation Admit Day
CPT Code 99221/18 99222/19 99223/20
History
HPI 4+ 4+ 4+
ROS 2-9 10+ 10+
PFSH 1 All 3 All 3
Exam (# systems) 5-7 8+ 8+
Medical Decision
Making
Straightforward
or Low
Moderate High
E&M examples
1. Case 1
+ POD 1 follow-up on peripheral catheter
+ HPI – 3 points
+ ROS – 10 points
+ PFSH – 1 point
+ Exam – 5 systems
+ MDM – High
+ Overall – 99232
+ Level 2 Inpatient Subsequent Care
2. Case 2
+ New consult on post-op Medicare patient
+ HPI – 4 points
+ ROS – 9 points
+ PFSH – 3 points
+ Exam – 8 systems
+ MDM – High
+ Overall – 99221
+ Level 1 Inpatient Admit Day
RVU Loss:
5.74 2.87
(halved)
2.87 X $34.61
= $99.32

32. Inpatient Consult
CPT Code 99251 99252 99253 99254 99255
History
HPI 1 - 3 1 - 3 4+ 4+ 4+
ROS None 1 2 - 9 10+ 10+
PFSH None None 1 All 3 All 3
Exam (# systems)
1 Area/
System 2 - 4 5 - 7 8+ 8+
Medical Decision
Making
St Fwd St Fwd Low Moderate High
E&M examples
3. Case 3
+ Consult on admission for acute abd pain
+ HPI – 4 points
+ ROS – 10 points
+ PFSH – 2 points, no discussion of family
hx
+ Exam – 8 systems
+ MDM – Low
+ Overall – 99253
+ Level 3 Inpatient Consult
4. Case 4
+ POD 1 follow-up on indwelling epidural
+ Overall – 01996
+ Daily Neuraxial Catheter Management

33. Inpatient/Observation Admit Day
CPT Code 99221/18 99222/19 99223/20
History
HPI 4+ 4+ 4+
ROS 2-9 10+ 10+
PFSH 1 All 3 All 3
Exam (# systems) 5-7 8+ 8+
Medical Decision
Making
Straightforward
or Low
Moderate High
Time-Based Inpatient E&M
Inpatient Consult
CPT Code 99251 99252 99253 99254 99255
History
HPI 1 - 3 1 - 3 4+ 4+ 4+
ROS None 1 2 - 9 10+ 10+
PFSH None None 1 All 3 All 3
Exam (# systems)
1 Area/
System 2 - 4 5 - 7 8+ 8+
Medical Decision
Making
St Fwd St Fwd Low Moderate High
Inpatient Subsequent Care
CPT Code 99231 99232 99233
History
HPI 1 - 3 1 - 3 4+
ROS None 1 2 - 9
PFSH None None None
Exam (# systems) 1 2 - 4 5+
Medical Decision
Making
Straightforward
or Low
Moderate High
30’ 50’ 70’
15’ 25’ 35’
20’ 40’ 55’ 80’ 110’
Over 50% counseling
or coordinating care

34. Blocks and units – Peripheral blocks
Patient Mgmt
Inpatient Consultation
Inpatient Admit Day
Inpatient Follow Up
Day
Epidural Follow Up
Service Billed (CPT) RVUs
(2018)
Consult Level 1 (99251) 1.38
Consult Level 2 (99252) 2.11
Consult Level 3 (99253) 3.25
Consult Level 4 (99254) 4.72
Consult Level 5 (99255) 5.68
Inpatient Admit Day Level 1 (99221) 2.87
Inpatient Admit Day Level 2 (99222) 3.87
Inpatient Admit Day Level 3 (99223) 5.74
Inpatient Subsequent Day Level 1 (99231) 1.11
Inpatient Subsequent Day Level 2 (99232) 2.06
Inpatient Subsequent Day Level 3 (99233) 2.95
Epidural Follow Up (01996) 3

35. Pre-anesthesia Evaluation
+Review hx, perform physical
+Assess anesthesia risk
+Collect relevant data (labs/studies)
+Discuss r/b, informed consent
+Develop anesthetic plan
+Timing:
+ Within 48 hr of surgery
+ Or within 30 days and updated within 48 hr
ASA
Guidance

36. Increased services
+Separately identifiable service is necessary to bill
>1 CPT code (Procedure + E/M) or separately
from anesthetic.
+A distinct, preoperative E/M service must be
supported by individual circumstances
including medical necessity and would not be
expected to be performed on a routine basis
ASA
Guidance

37. When in doubt, talk
it out

38. References
+ https://www.asra.com/news-publications/asra-newsletter/february-2020/february-2020-
asra-news/asra-news/2020/02/07/regional-anesthesia-billing-surgical-anesthesia-versus-
postoperative-analgesia
+ https://www.cms.gov/files/document/chapter2cptcodes00000-01999final112021.pdf
+ https://www.edmariano.com/resources/set-up
+ Greger, J, Williams, BA. Billing for Outpatient Regional Anesthesia Services in the United
States, International Anesthesiology Clinics. 2005;43(3): 33-41. doi:
10.1097/01.aia.0000166187.45449.44
+ https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-
relative-value-files/rvu21a
+ https://www.ama-assn.org/practice-management/medicare-medicaid/medicare-
physician-payment-schedules
+ https://www.asahq.org/quality-and-practice-management/managing-your-
practice/timely-topics-in-payment-and-practice-management/distinguishing-between-a-
pre-anesthesia-evaluation-and-a-separately-reportable-evaluation-and-management-
service