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ASA21RABilling
- 1. Optimizing Documentation for Regional Anesthesia Billing Purposes Brian F.S. Allen Associate Professor Director, Regional Anesthesiology & Acute Pain Medicine Fellowship Vanderbilt University Medical Center
- 3. Spoiler Alert! + Understand when a block is “separately reportable” + Avoid common pitfalls of billing codes, modifiers + Open lines of communication with billers & coders To view slides:
- 4. 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) + Payers generally pay a rate per relative value unit (RVU) + Medicare conversion rate: $34.8931 (2021) $33.5848 (2022) + 2021 Anesthesia conversion rate: $21.5600 !!! + Medicaid pays less, private payers generally pay more + Rate is modified by geographic location (GPCI) + Anesthesia uses a time-based RVU component + 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 AMA Payment Schedules
- 5. 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 ($34.8931 vs. $21.5600) +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
- 6. 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
- 7. 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)
- 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 Our Focus
- 9. 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
- 10. 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
- 11. Modifiers +22 – Challenging cases requiring extra care (e.g., BMI >40) – 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
- 12. 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)
- 13. 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 ___”
- 14. Sample note from Vanderbilt’s Epic +Customized our own notes +Created 3 separate note types: Neuraxial, Peripheral, Truncal +Minimized narrative elements +Extensively used Macros +Elements in the note serve various purposes + Communication among providers + Administrative, Quality improvement + Billing + Liability, Quality assurance + Multiple Uses
- 15. + Billing + Liability, Quality assurance + Communication among providers + Administrative, Quality improvement + Multiple Uses
- 16. + Billing + Liability, Quality assurance + Communication among providers + Administrative, Quality improvement + Multiple Uses
- 17. + Billing + Liability, Quality assurance + Communication among providers + Administrative, Quality improvement + Multiple Uses
- 18. Macros +Populate predefined selections +Speed documentation +Require attention to accuracy
- 21. Billing best practices for blocks + Communicate with billers and coders + 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
- 22. When in doubt, talk it out
Editor's Notes
- 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.
- 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)