Post-operative pain management poses documentation confusion which can be dealt with through outsourced medical coding services.

1. Reporting Post-Operative Pain Management -
Medical Coding Services Could Help
Post-operative pain management poses documentation
confusion which can be dealt with through outsourced medical
coding services
OUTSOURCE STRATEGIES INTERNATIONAL
8596 E. 101st Street, Suite H
Tulsa, OK 74133
www.outsourcestrategies.com | 1-800-670-2809

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Outsourced medical coding services could help hospitals in tricky situations where it isn’t clear
how to report certain procedures. One such cloudy area is post-operative pain management.
Accurately reporting post-operative pain management procedures is one of the most complex
issues facing anesthesiologists. Much of the complexity is the result of the confusion as to:
 Whether to bundle some of the procedures along with the main anesthesia process,
or
 To report them separately
The issue arises primarily when it comes to documenting pain blocks in the post-operative
stage. Detailed documentation becomes necessary as the post-operative pain injection must be
separately documented apart from surgical anesthesia. However, all payers do not require
similar documentation. The advantage of partnering with a medical billing and coding company
is that providers can avoid the confusion and intricacy associated with selecting the right codes,
stay away from erratic coding and prevent claim denials.
Documenting Post-operative Pain Block Separately
It would be better to administer post-operative pain block in response to the surgeon’s request.
The time for administering the block must be documented separately from the time for
anesthesia, unless the administration was done after the induction and before emergence. A
modifier -59 must be attached when applicable. The method for block administration must be
documented distinctly from that for surgical anesthesia administration. The reason for the
block and the specific pain site must be indicated. The type of catheter or block performed
must also be indicated.
According to the American Medical Association (AMA), pain management for post-operative
analgesia is more appropriate to be reported separately from the general anesthetic

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administration, irrespective of when the block procedure occurs – pre-operative or post-
operative. In spite of the AMA’s recommendation, commercial carriers may have different
billing and reporting policies.
CMS Clarifies the Situation
The National Correct Coding Initiative (NCCI) Manual of the CMS clarified in 2013 that:
 Epidural or subarachnoid injections containing diagnostic or therapeutic substance can
be reported within CPT codes 62310-62311 and 62318-62319 on the surgery date if they
have been administered for post-operative pain management.
 62310-62319 must not be reported for pain management in the post-operative stage if
an analgesic is injected through the same catheter used for administering the anesthetic
agent.
 If subarachnoid or epidural injections are used for the purpose of post-operative pain
management and not operative anesthesia, the NCCI Manual suggests reporting
modifier-59 for indicating that the aforementioned injection was used only for post-
operative pain management.
Hopefully this has cleared some of the confusion. However, this isn’t the only area where
complexity reigns. Outsourced medical coding services help many hospitals in situations such as
these, saving them time and ensuring they don’t encounter returned or unpaid claims.