Pain Block Coding & Billing: Q&A With Surgical Notes' Angela Mattioda
Angela Mattioda is senior vice president of revenue cycle management solutions and client experience for Surgical Notes.
Q: Why do pain blocks represent a good billing opportunity for ASCs?
Angela Mattioda: We frequently have new clients tell us that they perform pain blocks but only their anesthesia provider bills for them. Pain blocks are also billable services for ASCs as long as the surgeon orders the block for postoperative pain control, the order is included in the surgeon's operative note, and the biller has access to the block note from the anesthesia provider. The facility can bill the block without impacting anesthesia's ability to also bill the the block.
Q: What can ASCs expect to be paid for pain blocks?
AM: The average payment for a block is around $250 per case, but some contracts can reimburse an additional $2,000 or more, depending on how they are negotiated or methodology for reimbursement.
Q: How are pain blocks coded?
AM: Blocks are coded off the block note from the anesthesia provider. The block cannot be coded based on the operative note alone. The block note should indicate the type of block, location of the block, and confirmation that the block was ordered by the surgeon for postoperative pain control.
It's important to know that some Medicare regions consider peripheral nerve blocks to be inclusive to the procedure. Even though pain block codes may be on the fee schedule, they may not be paid based on local coverage determination.
CPT codes 64415-64418 are commonly used and typically payable, but some Medicare regions and commercial payers may consider them inclusive. The same can be said for CPT 64450-64454. HCPCS C9290 for Exparel is typical and payable by Medicare/Medicare Advantage and commercial payers, depending on their contracts. Finally, HCPCS C9088 for Zynrelef is common and often payable by Medicare/Medicare Advantage and commercial payers, depending on their contracts.
One other important factor for coding is to have the block note indicate if there were any amounts wasted when utilizing biologics such as Exparel and Zynrelef. The entire vial is reimbursable. However, if there is an unused portion of the vial, it should be reported on a separate line with modifier JW to report the discarded amount. Otherwise, modifier JZ should be reported to indicate there was no discarded amount. The reported units should coincide with the used and discarded amounts.
Q: How does Surgical Notes help clients get paid for performing pain blocks?
AM: When onboarding clients, we first determine whether these ASCs are performing pain blocks for postoperative pain control. We often see blocks used by ASCs performing orthopedic, podiatry, hand, and foot and ankle procedures.
We then provide clients with three options to choose from for how they would like to work with us to track and bill their pain blocks. These options are as follows:
1. Put a comment on the coding sheet that a nerve blocks was performed.
It's a compliance requirement for surgeons to dictate that they ordered the block for postop pain control due to the level of pain anticipated to be beyond the normal scope of pain expected. It's also a compliance requirement that the block be administered by someone other than the surgeon, typically the anesthesia provider.
If the surgeon fails to dictate the ordering of the block, we will likely miss that a block was administered, and it won't be billed. It's also important to understand that we cannot code a postoperative pain block based on the surgeon's operative note. However, it is required they order the block and that is documented.
Once the Surgical Notes' billing team sees the comment on the coding sheet that a block was indicated, we will pull the block note to send to our coding team so the entire case can be coded before it's billed.
Our intake team members know our clients well and are proactive when they see procedures performed that typically include blocks. These team members know to look for the block note in the area they are housed.
We discuss the above points with clients to better ensure we have access to the block notes and document in our client profile where the block notes are housed.
2. ASC nursing staff maintain a block tracker we use for reconciliation.
This is the best method for ensuring we do not lose revenue for blocks administered in the event a surgeon fails to dictate the block order.
Receiving timely pain block notes is critical to avoiding billing delays, so ask clients that want to have nursing staff use a block tracker to send information on their blocks to us at the end of each day or the next day for the previous day's cases. This process will allow Surgical Notes to reconcile the nerve blocks, provide feedback if the documentation is lacking, and avoid a loss of potential revenue.
3. Schedule the block code and/or schedule the anesthesia to be specific to the anesthesia type with the block.
If this method is used, our intake team knows to look for that information, when to pull the block note, and to keep track of blocks on an unbilled report.
If this method is used, we tell our clients that there could be lost revenue based on the scheduling team not inputting the proper selections during scheduling of cases. If the anesthesia entry is not accurate and the surgeon fails to dictate the block was ordered, Surgical Notes would not have a way to identify the missed opportunity.
The process to confirm all billable and reimbursable procedures, biologics, supplies, and implants are captured takes a team effort that involves many different parties. Defining the process that works best and ensuring all parties involved are clear on their requirements will help the facility maximize its revenue.