Postoperative Pain Blocks: What You Must Document

    By Justin Vaughn, MDiv, CPC

    At Medac, we are privileged to work with the finest anesthesia providers in the country. It is our purpose to submit your claims as quickly and accurately as possible.  To help ensure this, we monitor our groups’ documentation efficiency rates, and provide feedback when a troublesome trend is detected.  One of the items we find fairly regularly centers around post-op pain (POP) documentation.  All too often anesthesiologists and CRNAs fail to fully define or defend their POP block placements.  Accordingly, this article is submitted to remind our clients of the elements they must denote on the anesthesia record and/or block sheet to sufficiently support the separate billing of these acute pain procedures.

    Listing the required POP data elements on the medical record is akin to writing a story.  The sections below represent “chapters” in that story.  When one chapter is missing, there is a loss of comprehension and clarity.  Since our coders cannot engage in guessing, they are forced to generate information requests (IRs) that are sent to the group, requesting the missing data.  This takes time and slows down claims.  We therefore request that you remember to consistently document all of the following elements whenever a block is placed for the sole purpose of controlling postoperative pain.


    As you no doubt know, an acute pain block is not an anesthesia service (TOS 7), but rather a surgical procedure (TOS 2), for which you are separately paid.  We must submit the claim for such procedures in the name of the individual who actually performed it.  We cannot assume that the “attending” relative to the anesthesia service was the one who also placed the block.  Some cases may be medically directed.  In such cases, was it the physician or the CRNA who placed the block?  Some cases involve handoffs from one provider to the other.  Which of these providers performed the POP procedure?  Some groups have a dedicated “block doc” who spends much of his/her morning doing nothing except placing these POP blocks throughout the OR suite, allowing his/her partners to concentrate on the anesthesia service in their respective rooms.

    Since it is not always apparent who placed the block, it is imperative that the record specify this.  This data element can be clarified by simply dropping a note in the Comments section of the record, such as, “epidural placed by (list initials or last name), MD,” or some similar statement that will alert our team as to who performed the POP procedure.  If you send your consultants a separate block note with the performing provider’s signature, that will suffice.


    At whose request was the POP block placed?  The typical answer to this inquiry is “the surgeon.”  Where this is so, we recommend that your record template include this pre-formulated statement with checkbox:  “At surgeon’s request.”  This will help to support medical necessity questions that may arise among some payers.  Noridian, the Medicare carrier for many Western states, has directed surgeons to draft an order reflecting their request that post-op pain be transferred to the anesthesia provider, along with an explanation as to why they believe such a transfer to be necessary.  In addition, Noridian has mandated that the anesthesia provider must document an acceptance of, and rationale for, this transfer of care.  So, if you are under Noridian’s jurisdiction, you may want to broaden your embedded checkbox statement so that it additionally reflects the reason you believe your acceptance of postoperative pain care is, in fact, necessary.


    What procedure did you perform?  You will certainly need to document the name of the POP procedure (e.g., epidural, nerve block, etc.).  While this is a “no-brainer,” I don’t want anyone to accuse me of not addressing the most important chapter of the story!


    Which mode did you use in performing the POP procedure?  Here, we’re looking for a clarification of whether the epidural or spinal or nerve block was administered via a single injection or a continuous catheter.  As you may know, there are differences in codes and billing units based on which method of infusion is employed.


    It is not enough to simply write “epidural” or “nerve block.”  Proper coding requires our anesthesia business consultants to know a bit more as to the anatomical location of the placement.  If the POP procedure was an epidural, we need you to specify the spinal region.  This is because epidurals placed in the thoracic region, for example, require a different code than those placed in the lumbar region.  Similarly, don’t just state “nerve block;” rather, provide our anesthesia business consultants with an anatomical descriptor by specifying the nerve or region that was injected/infused/blocked (e.g., “femoral nerve block”).


    Many times, our anesthesia business consultants see records where two items are selected in the “Anesthesia Techniques” section, though this later turns out to be misleading.  Usually, when this occurs, the provider has circled or otherwise indicated both “General” and “Epidural.”  While the provider did not intend to indicate a combined anesthetic in this documentation scenario, that is exactly what some payers may presume from a payment perspective.  That is, they could conclude that the epidural was intended to augment the general as the case anesthetic.  In fact, I have seen a Medicare jurisdiction actually write that this would be their finding upon seeing such documentation.  This means you would receive no separate payment for what you meant to be a POP epidural.

    So, instead of indicating both “General” and “Epidural” within the Anesthesia Technique box, circle or check or list only “General” if that, in fact, was the only case anesthetic.  If the epidural was placed for the sole purpose of controlling post-op pain, then it would be inconsistent to list it in the Anesthesia Technique box.  Rather, you need to list the epidural or spinal or nerve block that was meant only for POP control in a separate section of the record.  In addition, you need to add “for post-op pan” next to your documentation of the POP procedure.  This will clarify for our coder and any potential auditor that the block qualifies for separate payment.  Some groups have revised their anesthesia record template to include a “Postoperative Pain” box.  The label itself acts to clarify that the block selected therein was placed for the sole purpose of controlling post-op pain, and not meant—in full or in part—as the case anesthetic.


    The American Medical Association (AMA) has ruled that you can bill anesthesia time during which you are placing a POP block or invasive line (both being separately reimbursed procedures) as long as the placement occurs after induction of the primary anesthetic and before emergence.  The implication is that even if you are past your “anesthesia start time,” and even if you are already in the OR (where anesthesia time is “on automatic”), we must carve out those minutes reflecting the time it took you to place the POP block if the placement occurred between the anesthesia start time and the induction time.  For example, assume the following:

    • You enter the OR with the patient at 0800, which acts as the anesthesia start time
    • You begin placing the POP block at 00805, and finish the placement process at 00814
    • You induce the general anesthetic at 00817

    In the above scenario, we would have to deduct 10 minutes (this assumes the placement’s start and stop times are “inclusive” minutes) from the total anesthesia time on the case.  Notice that since you are in the OR, anesthesia time automatically resumes immediately after the placement stop time—even though this occurs a few minutes prior to induction time.

    All this means that our anesthesia business consultants will need you to consistently provide ALL of the following data points as to the “When” of the story:

    • Start time of POP injection/placement
    • Stop time of POP injection/placement
    • Induction time (primary anesthetic, i.e., general, not Versed)

    Remember that the AMA rule allows you to bill anesthesia time during the POP procedure placement as long as it occurs between induction and emergence.  So, for providers who perform their POP procedures at the end of their cases, you may also want to document the time of emergence.  (We will head down this side road a little farther in another client alert.)

    Finally on this point, some may insist they need not provide these 3 or 4 time notations on every case involving a POP block because they always perform the block prior to the anesthesia start time, or after the anesthesia stop time.  If this applies to your entire group, our anesthesia business consultants invite the group president or practice administrator or equivalent authority to send us an email attesting to that fact.  For example:

    I hereby attest that all separately billable post-op pain blocks performed by members of (name of group) are performed prior to the anesthesia start time.  We will inform you if these conditions change.

    Such an attestation will be memorialized within our coding specifications for your account, and will relieve you of having to provide the above-referenced time notations on each such case.  This will also keep you from receiving IRs from Medac relative to this particular data element.


    If the block was placed with guidance from an ultrasound (USG), this needs to be documented, as USG is also deemed separately billable by our anesthesia business consultants.  You may recall from our previous alerts that in order to bill USG you must ensure that both the ultrasound image and ultrasound report are retained in the patient chart, making sure that both are retrievable and able to be associated with the applicable patient.  If the image is electronically retained, make sure the image is tied to that patient and DOS.  Some have assumed this to be the case only to find out later that the electronically stored images did not include patient identifiers.

    Medac’s policy is to bill the ultrasound if you document “ultrasound” or “USG” or some similar verbiage.  It will be up to you to alert your Anesthesia Business Consultants—either on a case-by-case basis or via an email attestation applicable to the entire group—if there is no image or no report properly retained.


    When you consistently tell our team the full story, by completing all the above chapters, we can speed up the claims submission process and save you the headache of dealing with POP-related IRs.  I want to thank you for your time in reviewing this information.  I know it’s a lot to take in.  We continue to be grateful for all you do to hone your documentation habits.

    • MEDAC – Committed to Continuing Client Education •

    The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, information provided by our anesthesia business consultants, and the author’s presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.