By far the most significant area of new procedures in most anesthesia practices these days is the administration of nerve blocks and catheters for the management of post-operative pain. There are many compelling reasons for this trend to continue. A good argument can be made that the targeted injection or infusion of certain pain-inhibiting drugs can and will reduce the need for opioids, which we all agree is a very important goal in the current environment. Ultrasonic guidance allows more providers to perform a wider variety of block techniques with greater proficiency. Thus far billings for nerve blocks and ultrasonic guidance have also enhanced practice revenue, although there is much concern that this will eventually diminish. For all the reasons to expand the group’s commitment to effective acute pain management many practices are still not realizing the full potential of such a service. Why is this?
The feedback from our clients is that many orthopedic surgeons are still not sold on the value of nerve blocks for post-op pain management of their patients. There are various arguments given why they do not want the anesthesia provider to perform blocks on their patients. The fact is there is much debate among surgeons about the clinical efficacy of blocks with the preponderance of younger orthopedic surgeons arguing for a more extensive use of blocks. This may be an issue of education or an issue of practicality. Some impatient surgeons simply do not want to wait for the block to be properly administered. In either case it may make sense for the department to develop an educational plan that identifies the clinical value of anesthesia’s role in acute pain management.
When we discuss the potential of an acute pain service with our clients, they often point out that not all physicians are equally skilled in the administration of nerve blocks. Typically, the younger members of the practice who are closer to their residency training are the most comfortable and eager to apply these techniques. Many practices have used the enthusiasm and skill of these younger providers to great advantage in training other members of the practice. The fact is that there are many seminars and programs physicians can attend to improve their skill in administering nerve blocks. It usually boils down to the commitment of the group to enhance this line of business.
There is a common saying in business that you cannot manage what you do not measure. We happen to believe that it is very helpful to develop and maintain a scorecard to your acute pain practice. While there are many specific approaches and techniques used in the administration of blocks for orthopedic and abdominal surgery, they are typically billed with just seven CPT codes listed below. Below is an example from a single practice, there is a code for a femoral block, 64447, which can also be used for an adductor canal block.
Each of these blocks is well suited to procedures in a specific region of the body. There are many ways to track nerve block utilization and many practices will tally how many blocks were billed by month. We believe it is more useful to track blocks based on the primary surgical procedure. The table below is an example of the most common surgical procedures for which interscalene blocks are performed. You will note that this format allows the practice to identify how often a block is used for each of the most common shoulder procedures and to evaluate it against a benchmark. Such data could be further assessed by a physician or surgeon.
It should be noted that any perceived shortcomings in the capturing of reimbursement relative these acute pain blocks could be the result of one of three factors. First, a block is sometimes contra-indicated based on patient-specific factors. Second, the provider may not always succeed in documenting that the block was (a) performed for purposes of post-operative pain management, and (b) at the request of the surgeon, as required. Third, a coder may occasionally fail to notice the block, though we believe this to be a rare occurrence.
It has become a de facto standard of care that ultrasonic guidance is used for virtually all blocks. Again, there are very specific documentation requirements that must be met. Failure to note that the image has been retained for possible audit and failure to explain the reason for using USG may result in the charge not being billed.
Payment for nerve blocks and USG varies by payer and average rates per CPT code should be determined on a practice by practice basis. In very general terms a block will be worth somewhere between $100 and $150 per procedure, and the USG should be worth $35 to $45 on average. For the most part, payers recognize and will pay for all the procedures listed above. The exceptions to this can be frustrating, however, and it is important that all charges be reviewed on a regular basis to ensure that payment has been received and that it is correct.
Advances in medicine have provided anesthesia practices with ever-increasing options to safely manage patients through the trauma of surgery. This is part of what makes anesthesia such an exciting field these days. Taking advantage of these advances, however, is not always easy for better patient care. As in the case of acute pain, successful implementation is a matter of clinical training and skill, appropriate documentation. If you want to know how your practice compares in this vital area, feel free to ask your account executive for a review. We will be happy to assist.
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