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APSBILLING 2022

Regional anesthesia and acute pain medicine billing is complex, with multiple factors to consider in determining the correct codes. Procedures may be billed as anesthesia with time units, procedural codes, or follow-up care. The purpose of the block, type of surgical anesthesia, and whether the block is separately reportable affect billing. Documentation of medical necessity, requests, and ultrasound use is important. Non-procedural acute pain service is usually billed under evaluation and management codes with caveats for epidural follow-up and inpatient billing.

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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
Disclosures No conflicts of interest. Not a billing or coding professional! My practice is hospital & ASC regional & acute pain (APS)
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!!!
(OVER)Simplified Billing & Coding Patient Care Documentation Systematized Reporting (Units) Submission Payment POINTS!
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
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), $20.7191 (2023) + Medicaid pays less, private payers generally pay more + Rate is modified by geographic location (GPCI) +Anesthesia uses BASE + TIME billing + Each CPT has a number of “base units” AND then additional units for time spent on a case (1 unit / 15 min) + Nerve blocks for surgical anesthesia are billed this way
Anesthesia Billing Basics +Regional block procedures for postoperative analgesia have their own CPTs without time units +To bill for postoperative analgesia, a block must be “separately reportable” +RVUs for these blocks are calculated at higher conversion rate ($ 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
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
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
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)
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
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
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
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)
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 ___”
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
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!
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
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”
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!!!
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
When in doubt, talk it out
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

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APSBILLING 2022

  • 1.
    Optimizing Documentation for RegionalAnesthesia & 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 ofinterest. Not a billing or coding professional! My practice is hospital & ASC regional & acute pain (APS)
  • 3.
    Complexity +“How do Ibill 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 +Billedservices 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 +Payersgenerally pay a rate per relative value unit (RVU) + Medicare conversion: $34.6062 (2022), $33.0775 (2023) + Anesthesia conversion: $21.5623 (2022), $20.7191 (2023) + Medicaid pays less, private payers generally pay more + Rate is modified by geographic location (GPCI) +Anesthesia uses BASE + TIME billing + Each CPT has a number of “base units” AND then additional units for time spent on a case (1 unit / 15 min) + Nerve blocks for surgical anesthesia are billed this way
  • 7.
    Anesthesia Billing Basics +Regionalblock procedures for postoperative analgesia have their own CPTs without time units +To bill for postoperative analgesia, a block must be “separately reportable” +RVUs for these blocks are calculated at higher conversion rate ($ 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 Whatis 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** LumbarEpidural 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 theBlock… 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 – Challengingcases 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 ofprocedural 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 beprovided 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 andModifiers 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 andModifiers 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 • Threetypes 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 Levelof 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 CPTCode 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 DecisionMaking 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 Levelof 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 DecisionMaking 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 DecisionMaking 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 DecisionMaking 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 DecisionMaking 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 CPTCode 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 CPTCode 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 Code99251 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 CPTCode 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 identifiableservice 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

Editor's Notes

  • #14 25 modifier – eval Each procedure has a built in level 2 E&M code. So you should pull out that complexity from consult if billing block and consult.
  • #22 All surgical procedures and some non-surgical procedural services include a certain degree of physician involvement or supervision, pre-service work, and post-service work which is integral to that service. For those procedures and services, a separate E/M service is not normally reimbursed. However, a separate E/M service may be considered for reimbursement if the patient’s condition required services above and beyond the usual care associated with the procedure or service provided and modifier -25 is appended to the E/M code. None of the usual pre-service, intra-service, or post-service work associated with the other procedure(s) performed on the same day may be included in the documentation to support the key components of the significant, separately identifiable E/M service. The documentation of the procedure and the documentation of the significant, separately identifiable E/M service must be clearly separate and distinct in the medical record to fulfill the requirements of “separately identifiable.” If both services are mixed in a single visit entry without any separation (e.g., under a sub-heading) to identify the separate and distinct nature of the services, then the requirement for a “separately identifiable” service has not been met.
  • #35 All surgical procedures and some non-surgical procedural services include a certain degree of physician involvement or supervision, pre-service work, and post-service work which is integral to that service. For those procedures and services, a separate E/M service is not normally reimbursed. However, a separate E/M service may be considered for reimbursement if the patient’s condition required services above and beyond the usual care associated with the procedure or service provided and modifier -25 is appended to the E/M code. None of the usual pre-service, intra-service, or post-service work associated with the other procedure(s) performed on the same day may be included in the documentation to support the key components of the significant, separately identifiable E/M service. The documentation of the procedure and the documentation of the significant, separately identifiable E/M service must be clearly separate and distinct in the medical record to fulfill the requirements of “separately identifiable.” If both services are mixed in a single visit entry without any separation (e.g., under a sub-heading) to identify the separate and distinct nature of the services, then the requirement for a “separately identifiable” service has not been met.
  • #38 A patient undergoing ACL repair receives an adductor canal block for postoperative analgesia. When generating a bill for anesthetic services, this block is coded as a femoral nerve block (64447). Coding an adductor canal block as a femoral injection is an example of which of the following practices?   A) Downcoding B) Crosswalking C) Balance billing D) Upcoding     A 24-year-old man receives an ultrasound-guided interscalene block for postoperative analgesia following shoulder surgery. In addition to billing for the nerve block, which of the following elements is required to bill the CPT code for ultrasound guidance (76942)?   A) Video of ultrasound guidance B) Written consent for nerve block C) An interpretation of imaging findings D) Documentation of block success       Which of the following regional procedures is associated with the LOWEST relative value unit (RVU) for billing?   A) Lumbar epidural without imaging guidance (62322) B) Femoral nerve block (64447) C) Suprascapular nerve block (64418) D) Injection of other peripheral nerve or branch (64450)