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ASA Offers NCCI Clarification

Wednesday, January 04, 2012

It is unfortunate that incomplete or erroneous information presented at a recent non-ASA sponsored webinar has caused confusion regarding the timing of blocks provided for postoperative pain.  Specifically, ASA staff and physician leaders have been asked to comment on the suggestion that pre or intra-operative performance of the block would be considered part of the anesthesia itself (bundled) as it may reduce the amount of agent required to perform the surgical procedure. The CMS National Correct Coding Initiative (NCCI) has introduced a few changes to the reporting guidelines in this area, but we do not believe these changes reflect new CMS policy.

Anesthesia for surgical procedures is reported with CPT codes 00100- 01999.  With only a few exceptions, these codes do not specify the type of anesthesia administered.  Blocks done as part of a combined technique were never separately reportable. However, single shot nerve blocks performed pre- or intra-operatively for the intended purpose of post-operative pain control do not represent a combined technique.  Similarly, a catheter placed pre- or intra-operatively is not part of a combined technique even if a small test dose is administered to confirm catheter placement, provided that the test dose is not intended to provide surgical anesthesia and does not, in fact, produce surgical anesthesia.  The intended purpose of the single shot block or catheter placement is dependent upon the specific clinical situation and the anesthesiologist’s documentation should clearly describe the circumstances and purpose of the block.

A pain procedure is (and remains) separately reportable from an anesthesia service if it is used to provide post-operative analgesia and is not used to provide anesthesia for the surgical procedure.

This issue is addressed in the ASA Statement “Reporting Postoperative Pain Procedures in Conjunction with Anesthesia.  Relevant excepts include:

“…A provider may bill for a regional anesthetic technique as a service separate from the anesthetic if the regional technique is employed primarily for postoperative analgesia and if the following conditions apply:
1.1 The anesthesia for the surgical procedure was not dependent upon the efficacy of the regional anesthetic technique
1.2 The time spent on pre-or postoperative placement of the block is separated and not included in reported anesthetic time
1.3 Time for a post surgical block that occurs after induction and prior to emergence does not need to be deducted from reported anesthesia time"

The complete statement is available here

Nerve blocks placed pre- or intra-operatively for the purpose of post-operative pain control can be submitted with the CPT code describing the particular nerve block with modifier 59 appended to the code to indicate that it is a separately reportable procedure.  Chapter 2 of the National Correct Coding Initiative Policy Manual for Medicare Services (“NCCI Manual”) includes the following:

“CPT codes 64400-64530 (Nerve blocks) may be reported on the date of surgery if performed for postoperative pain management.  Nerve block codes should not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique.  Modifier 59 may be utilized to indicate that a nerve block injection was performed for postoperative pain management, rather than intraoperative anesthesia, and a procedure note should be included in the medical record.”

This statement clarifies that nerve blocks not intended as the primary anesthetic technique or as a supplement to the primary anesthetic technique (often referred to as a combined technique) are separately reportable.  Nothing in this statement indicates that such blocks placed pre- or intra-operatively are not separately reportable.  The statement goes on to instruct physicians to include modifier 59 to indicate that the block is a separate service from the anesthetic technique.  Anesthesiologists placing these blocks should clearly indicate that the surgeon requested the block in the procedure note, which should be a separate entry in the medical record, and not part of the anesthesia record, to clearly indicate that the block is not part of the anesthetic.

Recent discussions have explicitly mentioned single shot epidurals as described by CPT codes 62310 and 62311.  The NCCI Manual provides the following clarification, which also notes that these specific procedures may be separately reported from an anesthesia service when they meet the criteria:

“CPT codes 62310-62311 and 62318-62319 (Epidural or subarachnoid injections of diagnostic or therapeutic substance) may be reported on the date of surgery if performed for postoperative pain management rather than as the means for providing the regional block for the surgical procedure. If a narcotic or other analgesic is injected postoperatively through the same catheter as the anesthetic agent, CPT codes 62310-62319 should not be reported for postoperative pain management. However, if epidural or subarachnoid injections are not utilized for operative anesthesia, but are utilized for postoperative pain management, modifier 59 may be reported to indicate that the epidural/subarachnoid injection was performed for postoperative pain management rather than intraoperative pain management.”

Similar to the statement regarding nerve blocks, nothing in this statement indicates that an epidural placed for the purpose of post-operative pain control is not separately reportable, even if it is placed pre- or intra-operatively, so long as it is not placed as the means for providing the regional block for the surgical procedure.  The anesthesiologist placing an epidural for post-operative pain control should document that the surgeon requested the epidural for post-operative pain control in a procedure note in the medical record that is separate from the anesthesia record.   

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