January, 2005

Nearly everyone who's directly experienced regional blocks understands that they are a true “win-win.” For patients, they dramatically cut pain and post-op surgical stress syndrome (delayed recovery, immunosuppresion, fatigue, hypoxia, nausea, ileus and sleep disturbances). For facilities, they help meet the new post-op pain guidelines mandated by accreditors. For anesthesiologists, they produce better outcomes.

For insurers, blocks are also a win, as they produce satisfied customers and lower pain medication and rehab costs. Unfortunately, some in this last group still poorly understand blocks and are reluctant—sometimes maddeningly so—to reimburse for them. Here are tips on how to educate them.

Until the insurer understands blocks, file claims on paper, not electronically. I recommend developing an all-in-one form that includes

Diagnosis	Code	Diagnosis	Code
Ankle	719.47	Hip	719.45
Arm upper	719.42	Knee	719.46
Elbow	719.42	Lower leg	719.46
Forearm	719.43	Foot	719.47
Hand	719.44	Thigh, pelvic	719.45
Wrist	719.43	Shoulder	719.41

• the type of procedure performed
• indications and diagnosis
• the surgeon's signed request for post-op pain management (a Medicare requirement).
• description of the procedure performed
• date the procedure was performed
• signature of the person performing the procedure; and
• a statement that the block was performed pre- or post-anesthesia in a place other than the operating room.

If possible, use two anesthesiologists. If the anesthesiologist who administers the block is different than the one who does the case, you will face denials less often.

Use the right diagnosis code. When billing for a block for post-op pain control, you must use a diagnosis code. Do not use a code that justifies surgery. For example, use the code for shoulder pain, not torn rotator cuff. The codes are as follows:

Use the right codes:

Single injection blocks

Block	Code	Unit Worth
Brachial plexus	64415	8
Axillary	64417	8
Sciatic	64445	7
Femoral	64447	7
Lumbar plexus	62319	9
Other peripheral nerve branch	64450	5

Change your paradigm. Unlike MAC or general anesthesia delivery, which is a type of service 7 and billed according to time, blocks are type of service 2 and are billed in units.

Use the right modifiers. Here are a few tips: - Use modifier 59 for all blocks. This serves to unbundled the block from the standard general anesthesia charge. - If the procedure is bilateral, add the modifier 50. For example if you place two femoral nerve block catheters for a bilateral total knee case, code 64448-59-50. - When doing multiple blocks on the same extremity, use the modifier 51. An example might be a sciatic catheter and single shot femoral block for an ORIF of the ankle. Fully bill for the sciatic catheter with modifier 59 and then bill for the femoral with a modifier 59 and 51. In this case, the second block will be reimbursed at half the normal charge.

Catheter insertion

Block	Code	Unit Worth
Lumbar plexus	64449	12
Femoral	64448	12
Sciatic	64446	12
Brachial plexus	64416	13
Note: Catheter codes include daily management for a 10-day period. (Source: American Society of Anesthesiology Relative Value Guide).

If your claim is denied, carefully review the insurers' explanation of benefits. Sometimes simple errors such as an incorrect zip code are the problem; a simple resubmission is in order. Other times the reasons are more complex, as when the insurer believes the procedure was not medically necessary. You can still successfully appeal if you possess the documentation described above.

Remember that persistence pays off. Helping insurers understand blocks can be frustrating, but ultimately it's a battle that can and will be won. Changing this paradigm is a must, if for no other reason than because our cause is just.

Dr. Greger, formerly director of regional anesthesia at the University of Texas Health Science Center, currently is in private practice specializing in regional anesthesia.